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m- 


VOLUME  XXVIII. 


®^l^  llptcian  anlr  ^m^m 


A  PROFESSIONAL  MEDICAL  JOURNAL. 


BDITBU  BT 

JOHN  WILLIAM  KEATING,  M.  I). 

WITH  THB  COLLABORATION   OF 

GBOBGE  DOCK,  M.  D. 

REUBEN  PETERSON,  Iff.  D. 

ALDRED  BCX>TT  WARTHIN.  M.  D. 


WALTER  ROBERT  PARKER,  M  D. 
FRANK  BANGHART  WALKER,  M.  D. 
ALBERT  MOORE  BARRBTT,  M.  D. 
R.  BISHOP  OANFIELD.  M.  D. 
WILLIAM  FLEMING  BRBAKET.  M.  D 
WILLIS  SIDNEY  ANDERSON,  M.  D. 
VERNON  JUSTIN  WILLEY,  M.  A. 
WILLIAM  HORACE  MORLEY.  M.  D. 
IRWIN  HOFFMAN  NEFF,  M.  D. 


DEL08  LEONARD  PARKER,  M.  D. 
OYRENUS  GARRITT  DARLING,  M.  D. 
DAVID  MURRAY  COWIE,  M.  D. 
IRA  DEAN  LOREE,  M.  D. 
JAMES  FLEMING  BREAKEY,  M.  D. 
CARISTOPHER  GREGG  PARNALL,  M.  D. 
GUY  UNCOLN  KIEFER,  M.  D. 
MARSHALL  LAWRENCE  CUSHMAN.  M,  D. 
LOUIS  JACOB  HIR8CHMAN,  M.  D. 
ARTHUR  DAVID  HOLMES,  M.  D. 
ROLLAND  PARMETER.  M.  D. 
DAVID  INGLIS,  M.  D. 


JANUARY  TO  DECEMBER. 


COPYRIGHTED 

Founded  bt  JOHN  WILLIAM  KEATING.  M.  D.,  January,  1879 

DETROIT  AND  ANN  AKBOR, 

MICHIGAN. 

1900 


AUTHORS. 


Anderson,  Willis  S.,  31,  82,  133, 
225,  26s,  320,  364, 
Akonstam,  Noah  £.,  . 
Barhbtt,  Albert  M.,   . 
Benn,  Walter  J.,       . 
Blodgett,  William  E., 
BoDiNE,  John   A.,   18,  21,  22,  74, 
Bradley,  Ernest  B.,    . 
Breakey,  James  P.,  135,  227,  267, 
Breakey,  William  F., 
Canfield,  R.  Bishop,  30,  80,  224, 
Caulkins,  John  S.,  118.  245,  302, 
Chetwood,  Charles  H., 
Child,  Charles  G.,  Jr., 
Collins,  Alvah  N.,    . 
Cook,  Anna  Marion,  . 
CowiE,  David  M.,      128,  173, 
Cushman,  Marshall  L.,  363, 
Darling,  Cyrenus  G.,  24.  129, 

Dawbarn,  Robert  H.  M.,    . 
de  Nancrede,  Charles  B.  G., 
Dock,  George,  23,  65,  75,  413,  470, 
Edgerton,  Joseph  I.,  . 
Freund,  Hugo  A.,  389, 

FuLD,  Joseph  E., 
Gates,  Neil  A.,  . 
Grosh,  Lawrence  L.. 
HiRSCHMAN,  Louis  J.,  83,  134,  179, 
'  320,  36s, 
Holmes,  Arthur  D.,  27,  77,  133, 
221.  317,  361, 
Keller,  Frederick  C, 
Keyes,  Edward  L.,  Jr., 
Klingmann,  Thbophil, 
Knapp,  Don  D.,  . 


218,  289, 


219, 
313, 


Page. 

178, 

409»  507 

.  492 

.  563 

•  3" 

97,  400 

125,  127 
.  536 

3^,  510 
.32,  385 

465,  471 

351,  396 
.  74 
.  127 
.  208 
289 
I,  446 

506,  561 

257, 

458,  500 

21 

.     49 

481,  557 
.   170 

446,  469 

20,  217 

.  250 

.  529 
266, 

4",  510 
177, 
406,  504 

.   125 

.   168 
68,558 

.  560 


Kuhn,  Charles  F., 

Ladinski,  Louis  J., 

Larkin  John  H., 

LoREE.  Ira  D.,  28,  78,  i 

Lyle,  Alexander, 

Lyman,  William  R., 

Miller,  Paul  S., 

Morley,  William  H. 

McGraw,  Theodore  A 

McKee,  Edward  S., 

Neff,  Irwin  H.,  35,  62,  84,  136, 

268,  321,  37^.  412, 
Parker,  Delos  L.,  36,  85,  229,  323, 
Parker,  Walter  R.,     .         29,  79, 
Parmeter,  Rolland,    . 
Parnall,  Christopher  G.,  25,  66, 

131,  176,  315.  360, 
Pedersen,  Victor  C,  . 
Peterson,   Reuben, 
Porter,  Miles  F., 
Robinson,  Andrew  R., 
Signor,  Wales  Melvin, 
Sinclair,  Daniel  A.,  . 
Slocum,  George, 
Smithies,  Frank, 
SoLis,  Jeanne  C, 
Taylor,  Joseph  C, 
Vaughan,  Victor  C,  . 
Walker,    Frank    Banghart,   76, 

241 
Wallace,  James  B., 
Warthin,  Aldred  S., 
WiLLEY,  Vernon  J., 
Wyman,  Hal  C, 
Yeomans,  Frank  C, 


Page. 

.  164 

20 

.  217 

319,  407 
126,  215 

•  255 
.  343 
26,  113 
.  13 
.  494 
228, 

488,  513 
372,  514 
224,  497 
.  404 
.  76, 
403.  502 

214.  215 

461,  499 
.  i6q 

145,  433 

47,  316 
.  171 
.  337 
.  467 
.  564 
.  123 
I 

173, 

259,  402 
.  121 
.  544 

193,  512 
.  200 
.  215 


ARTICLES. 


Abdominal  section,  preoperative  treatment 
for,  433. 

Abortion,  treatment  of,  76. 

Abscess,  inferior  retropharyngeal,  follow- 
ing the  removal  of  adenoids  in  an  adult, 

507. 
Actinomycosis  of  the  neck,  365. 
Adenoids,  255. 

in     an    adult,    inferior    retropharyngeal 

abscess  following  the  removal  of,  507. 

Alimentary  canal,   rythmic  sounds  of   the, 

128. 
Anesthesia  in  rectal  surgery,  266. 
in  the  first  stage  of  labor,  316. 
steiile  water,  in  operative  treatment  of 
diseases  of  rectum  and  anus,  510. 
Anesthetic  aid,  scopolamine  as  an,  76. 
Aneurysm,  cardiac,  65. 
of  the  abdominal  aorta,  a  case  of,  343. 
of  the  aorta,  467. 
of  the  arch  of  the- aorta,  557. 
Ani,  fissure  in,  and  divulsion  of  the  sphinc- 
ter, 179. 
pruritus,  treatment  of,  365. 
Anus  and  rectum,  sterile  water  anesthesia 
in  operative  treatment  of  diseases  of, 
510. 
Aorta,  abdominal,  aneurysm  of  the,  343. 

aneurysm  of  the,  467. 
Appet\dages,  diseased,  217. 
Appendicostomy,  411. 
Arhythmias,  cardiac,  529. 
Argyrol   and  protargol   as   substitutes    for 

nitrate  of  silver,  29. 
Atresia  of  the  bowel,  20. 
Atrophy,    infantile,    etiology    and    dietetic 
treatment  of,  506. 

B 

Bacteria  in  scarlatinal  and  normal  throats, 

S08. 
Bier's  hyperemia,  506. 
Bile    passages    and    gall-bladder,    mortality 

after  operations  upon  the,  402. 
Bowel,  atresia  of  the,  20. 

diagnosis  of  acute  obstruction  of,  13. 


Bone,  frontal,  gumma  of  the,  215, 
Bowels,  locking  of  the,  83. 
Brain  tumors,  84. 
Bronchiectasis,  469. 

0 

Caesarean  section,  26. 

Calculi,     renal,    nephrectomy     for    hydro- 
nephrosis due  to,  499. 
Cancer  of  the  larynx,  265. 
of  the  skfn,  influence  of  light  in  produc- 
tion of,  32. 
of  the  uterus,  radical  operation  for,  25. 
probable  hepatic,  560. 
Carcinoma,  partial  gastrectomy  for,  170. 

primary  basal-celled,  of  the  appendix,  544. 
Cardiac  aneurysm,  65. 

arhythmias,  529. 
Carpus,  tuberculosis  of  the,  214. 
Cell,  living,  some  new  conceptions  of  the,  i. 
Cells,  ethmoid,  orbital  and  meningeal  infec- 
tion from,  82. 
Cerebral  tumor,  mental  symptoms  of,  228. 
Cerebrospinal  fluid,  the,  in  health  and  dis- 
ease, 514. 
meningitis,  acute  pneumococcic,  of  nasal 

origin,  389. 
meningitis,  treatment  of,  260. 
Childhood  and  infancy,  the  weights  of  the 

viscera  in,  505. 
Cholecystitis,  acute  infections,  22. 
Chondritis  and  perichondritis,  auricular,  507. 
Chorea,  a  case  of  Sydenham's,  558. 

actue,  a  case  of,  68. 
Colic,  diagnostic  significance  of,  173. 
renal,  168. 

renal,  artificial,  as  a  valuable  means  of 
diagnosis,  502. 
Congenital  coxa  vara,  178. 
Constipation,  "spastic,"  83. 
Corneal  wounds,  infection  of,  by  saliva,  264, 
Coxa  vara,  congenital,  178. 
Cyst,  dermoid,  21. 
large  ovarian,  127. 
ovarian,  with  twisted  pedicle,  66. 


ARTICLES. 


Cysts,  ovarian,  situated  above  the  superior 
pelvic  strait,  complicated  by  pregnancy, 
403. 

D 

Deformities,  and  their  prevention,  78. 
Dementia  paralytica,  early  ocular  signs  of, 

136. 

paretic,  the  clinical  aspects  of,  with  special 
reference  to  differential  diagnosis,  488. 

Dermatoses,  the  unsuspected  parasitic  origin 
of  many,  385. 

Dermoid  cyst,  21. 

Diet  in  epilepsy,  35. 

Digestive  and  respiratory  passages,  133. 

Diphtheria,  uncertainties  of  early  diagnosis 
and  necessity  of  early  and  vigorous 
treatment  of,  27. 

Dislocation  of  humerus,  congenital,  subacro- 
mial, excision  of  the  head  of  the  hu- 
merus for,  28. 

Duodenum,  observations  upon  the  anatomy 
of  the,  403. 

Dysmenorrhea,  an  unusual  case  of,  121. 

E 

Ear    disease,    chronic    suppurative    middle, 

471- 
middle,  acute  suppuration  of,  224. 
middle,  suppuration,  following  intranasal 

operation,  80. 

Editorial  : 

Absinthism  in  comparison  with  alcohol- 
ism, 473. 

A  discovery  regarding  dead  tubercle  bacil- 
li, 187. 

An  appeal  in  behalf  of  blind  artisans,  376. 

American  Medical  Association  meeting, 
269. 

Anesthesia  without  subjective  annoyance, 
418. 

A  new  trypanosome  peculiar  to  tropical 
Africa,  5x6. 

A  novel  method  of  reducing  infant  mor- 
tality, 5x7. 

A  purifier  for  the  lacteal  product,  418. 

A  quick  means  of  preserving  milk,  87. 

A  record  of  the  heat  intensity  of  radium, 

138. 

A  score  for  radium  in  surgery,  374. 
A  word  to  the  wise,  327. 


Editorial  (Continued)  : 
Bactericidal    action    of    properly   brewed 

tea,  517. 
Baldness  ascribed  to  improper  breathing, 

137. 
Baron  Takaki's  observations  on  beriberi, 

417. 

Canine  disease  consequential  to  coitus,  474. 

Decrees  affecting  nasal  deformity,  517. 

Discord  among  doctors,  324. 

Disinfecting  possibilities  of  bacteria  pecu- 
liar to  the  intestinal  tract,  515. 

Doctor  Reed  on  race  suicide,  233. 

Gonorrhea  of  the  female  genitalia,  474. 

Herdman,  William  James,  Ph.  B.,  M.  D., 
LL.  D.,  564. 

Hypnotism:  its  history,  nature,  and  use, 
376,  418,  S18,  567. 

Investigations  bearing  on  animal  intelli- 
gence, 272. 

Insects  as  spreaders  of  infection,  139. 

Lead  colic  resultant  from  carbonated 
water,  517. 

Live  babes  from  pregnant  subjects  of  lues, 
139. 

Malaria  ascribed  to  ankylostoma  duoden- 
ale,  326. 

Medical  classics  in  medical  meeting,  180. 

Medical  investigation  of  the  pestiferous 
mosquito,  566. 

Medicine  in  popular  magazines,  138. 

Obligative  anaerobes  cultivated  in  the 
presence  of  oxygen,  566. 

Observations  in  animal  optics,  89. 

Occult  therapy  in  the  Ottoman  Empire, 

139. 
Pedal  characteristics  of  different  peoples, 

41. 
Physicians  and  philosophers,  42,  90,  234, 

273,  327. 
Physiologic  function  of  the  pituitary  body, 

41. 

Salt-free  diet  in  scarlet  fever,  416. 

Some  peculiarities  of  the  spirochaeta  pal- 
lida, 417. 

Stoicism  of  earthquake  sufferers,  273. 

Studies  in  simian  vernacular,  88. 

Surgical  anesthesia  by  scopolamin-mor- 
phin,  187. 

The  benignity  of  dessicated  tubercle  bacil- 
li, 474. 


ARTICLES. 


Editorial  (Continued)  : 

The  catastrophe  of  the  coast,  187. 

The  demise  of  Professor  Curie  in  Paris, 

233. 

The  influence  of  mineral  water  on  mi- 
crobes, 272. 

The  mechanical  treatment  of  mal  de  mer, 

41. 

The  new  clinic  in  psychiatry  at  the  Uni- 
versity of  Michigan,  37. 

Theories  appertaining  to  appendicitis,  89. 

The  Portuguese  intematfonal  congress  of 
physicians,  231. 

The  San  Francisco  earthquake  and  the 
doctors,  373. 

The  scientific  achievements  of  Schaudinn, 

375- 

The  Toronto  meeting  of  the  British  Med- 
ical Association,  413. 

The  treatment  of  cancer  with  trypsin,  232. 

The  treatment  of  sarcoma  with  mixed 
toxins,  40. 

The  tulase  discovery  for  tuberculosis,  472. 

The  ubiquity  of  cell  understanding,  326. 

Tubercle  bacilli  in  phthisic  blood,  474. 
Klectricity,  static,  experience  with,  250. 
Encephalitis  and  poliomyelitis  in  children, 

361. 

Enuresis,  treatment  of,  260. 
Epilepsy,  diet  in,  35. 
Ethics  and  etiquette,  medical,  ^82. 
Etiquette  and  ethics,  medical,  482. 
Eye,  injuries  of,  following  paraffin  injections 
in  the  nose,  79. 

F 

Faucial  tonsils,  lymphatic  drainage  of,  31. 
Feeding,  influence  of,  on  infant  mortality, 
221. 
in  infants,  177. 
Fever,  hay,  palliatives  for,  409. 
Malta,  75. 

scarlet,  complications  of,  317. 
Fissure  in  ani,  and  divulsion  of  the  sphinc- 
ter, 179. 
Fistula,  labyrinthine,  and  paralysis  of  the 
abducens  nerve,  complicating  a  case  of 
middle  ear  suppuration,  224. 
urethral,  and  prolapsed  kidneys,  74. 
Fistulas,  treatment  of  certain,  176. 
Foot,  destruction  of  tissue  and  nails  of,  215. 


Fracture,  modern  treatment  of,  129. 
of  the  ulna  during  massage  following  op- 
eration for  Colles'  fracture,  125. 
uncommon,  258. 
Furunculosis   and    mastoiditis    in    external 
auditory  meatus,  561. 

G 

Gall-bladder  and  bile  passages,  mortality 
after  operations  upon  the,  402. 

Gangrene  of  the  tonsil,  134. 

Gastrectomy,  partial,  for  carcinoma,  170. 

Gastric  surgery  and  chronic  ulcer,  313. 

Genitalis  tractus,  pathologic  physiology  of 
the,  145. 

Goitre,  exophthalmic,  500. 

Growths,  innocent  laryngeal,  364. 

Gumma  of  the  frontal  bone,  215. 

Gunn,  Moses,  49. 

H 

Headache,  persistent,  unilateral,  due  to 
nevoid  changes  in  the  anterior  extrem- 
ity of  the  middle  turbinal  bone,  509. 

Heart  disease  of  nephritis,  cause  and  im- 
portance of,  23. 

Hemorrhoids,  internal,  office  treatment  of, 
320. 
treatment  of,  134. 

Hepatic  cancer,  probable,  560. 

Hip  disease,  the  conservative  treatment  of, 
407. 

Humerus,  excision  of  the  head  of,  for  con- 
genital subacromial  dislocation,  28. 

Hydrocephalus  and  rachitis  treated  by  radi- 
ant energy,  317. 

Hydronephrosis  due  to  renal  calculi,  ne- 
phrectomy for,  499. 

Hyperemia,  Bier's,  506. 


Indigestion,  fat,  in  infants,  259. 

Infancy  and  childhood,  the  weights  of  the 

viscera  in,  505, 
Infant  feeding,  rural  city  milk  supplies  and 

their  relation  to,  289. 
Infantile  atrophy,  etiology  and  dietetic  treat- 
ment of,  506. 
paralysis,  cerebral  and  spinal,  361. 
pneumonia,  cold-air  treatment  of,  406. 


ARTICLES. 


Infant  mortality,  influence  of  feeding  on, 

221. 

Infants,  fat  indigestion  in,  259. 

substitute  feeding  in,  177. 
Infection  of  corneal  wounds  by  saliva,  264. 
Infections,  acute  pelvic,  123. 

cholecystitis,  acute,  22. 
Insanity,  borderland  cases  of,  62. 
Intussusception,  126. 


Jaundice,  obstructive,  Courvoisier's  law  in 
the  differential  diagnosis  of,  218. 

K 

Kidneys,  prolapsed,  and  urethral  fistula,  74. 


Labor,  anesthesia  in  the  first  stage  of,  316. 

conduct  of,  during  second  stage,  113. 
La  grippe,  remarks  on,  118. 
Laryngeal  growths,  the  patholog>'  of  fifty 

cases  of  innocent,  364. 
Leprosy  or  syringomyelia,  74. 
Ligaments,  round,  shortening  of  the,  315. 
Lipoma,  polypoid,  of  the  tongue,  508. 
Longevity,  lessons  in,  245,  302,  351,  396. 
Lupulin,  therapeutics  of,  229. 
Luxation,   congenital,   of  the  head   of  the 

radius,  97. 

M 

Mastoid  process,  necrosis  of  the,  311. 
Mastoidectomy  sinus  thrombosis,  30. 
Mastoiditis    and    furunculosis    in    external 
auditory  meatus,  561. 
with  Bier's  hyperemia,  and  acute  purulent 
otitis  media,  treatment  of,  506. 
Medical  mistakes,  160. 
Medical  News  : 
A  compilation  of  centenarians,  571. 
A  grist  of  medical  graduates,  236. 
American  Medicine  becomes  a  monthly, 

140. 
Ann  Arbor  meeting  of  nurses'  association, 

188. 
Annual    meeting   of    the    Roentgen    Ray 

Society,  332. 
A  physician  granted  patronymic  appella- 
tion, 44. 


Medical  News  (Continued)  : 
Arkansas  meeting  of  Valley  Association, 

422. 
Commencement  season  clinic,  278. 
Dedicatory  ceremonies  at  Harvard  Col-" 

lege,  475. 
Life  insurance  examination  fees,  279. 
Prepared  food  products,  331. 
The  Aesculapian  grist  at  Ann  Arbor,  382. 
The  demise  of  De  Wecker,  44. 
The  demise  of  Doctor  Doremus,  189. 
The  national  medical  election,  278. 
The  passing  of  a  pioneer  Detroit  physi- 
cian, 475. 
The  Peninsular  gathering  of  physicians, 

278. 
The  prevention  of  "putrifaction,"  523. 
The  sudden  demise  of  Schaudinn,  331. 
Ziegler,  Professor  Ernst,  92. 
Minor  intelligence,  44,  92,  141,  190,  236, 
282,  332,  382,  424,  475,  523,  572 
Medicolegal  questions,  494. 
Meniere's  disease  and  Meniere's  symptoms, 

322. 
Meningitis,    acute    pneumococcic    cerebro- 
spinal, of  nasal  origin,  389. 
cerebrospinal,  treatment  of.  260. 
Mental  diseases,  types  in,  268. 
Meralgia  paresthetica,  267. 
Metatarsalgia,  400. 
Milk  supplies,  rural  city,  and  their  relation 

to  infant  feeding,  289. 
Morphin  poisoning,  171. 
Myasthenia    gravis,    clinical    history    and 
postmortem  examination  of  five  cases 
of,  371. 
Mycosis  occurring  in  the  upper  respiratory 
tract,  224. 

Nasal  insufficiency,  409. 

obstruction,  etiology  of,  178. 
Necks,  broken,  observations  on,  319. 
Necrosis  of  the  mastoid  process,  311. 
Nephrectomy,  215. 
for  hydronephrosis  due  to  renal  calculi, 
499. 
Nephritis,  heart  disease  of,  cause  and  im- 
portance of,  23. 
Neuralgia,    trigeminal,    the   surgical    treat- 
ment of,  513. 
Nodes,  cervical  lymph,  tuberculosis  of  the, 
24- 


ARTICLES. 


Nose,  paraffin  injections  in  the,  injuries  of 
the  eye  following,  79. 
treatment    of    empyemata    of    maxillary 
..inus  through  the,  82. 
Nostrum  evil,  85. 

o 

Obituaries  : 

Allen,  Charles  Warren,  335. 
Cook,  Emma,  237. 
Curie,  Professor,  233. 
De  Wecker,  Baron,  44. 
Dor  emus,  Robert  Ogden,  189. 
Dunning,  Lehman  H.,  93. 
Herdman,  William  J.,  564. 
Schaudinn,  Fritz,  331. 
Skelton,  Leonard  Lawshe,  141. 
Stewart,  Morse,  475. 
Twecdie,  Henry,  526. 
Wilson,  Jeremiah  C,  525. 
Wooster,  Samuel  R.,  94. 
Ziegler,  Professor  Ernst,  92. 
Obstruction  of  the  bowel,  diagnosis  of  acute, 

13. 

Opsonins,  536. 

Orbit,  tumor  of,  497. 

Osteitis,  tuberculous,  of  the  knee,  early  op- 
erative treatment  of,  261. 

Otitis,  chronic  purulent,  what  cases  of  re- 
quire the  radical  operation,  408. 

Otitis  media,  acute  purulent,  and  mastoid- 
itis with  Bier's  hyperemia,  treatment  of, 

506. 

Ovarian  cysts  situated  above  the  superior 
pelvic  strait,  complicated  by  pregnancy, 
403. 


Paralysis,  cerebral  and  spinal  infantile,  361. 

Paralysis  of  the  abducens  nerve,  224. 

Parasitic  origin  of  many  dermatoses,  385. 

Paretic  dementia,  the  clinical  aspects  of, 
with  special  reference  to  differential 
diagnosis,  488. 

Parturition,  value  of  time  and  natural  uter- 
ine efforts  in,  208. 

Pathlogic  physiology  of  the  tractus  geni- 
talis, 145. 

Pelvic  infections,  acute,  123. 
strait,  ovarian   cysts  situated  above  the 
superior,  complicated  by  pregnancy,  403. 

Perichondritis  and  chondritis,  auricular,  507. 


Peritonitis,  bacteriology  of,  in  relation  to 
pelvic  surgery,  131. 

Physicians,  embarking,  practical  discourse 
to,  241. 

Physiology,  pathologic,  of  the  tractus  geni- 
talis, 145. 

Pneumonia,  infantile,  cold-air  treatment  of, 
406. 
lobar,  in  infants  and  children,  133. 

Poisoning,  morphin,  case  of,  171. 

Poliomyelitis  and  encephalitis  in  children, 

361. 

Polypoid  lipoma  of  the  tongue,  508. 

Pregnancy  complicated  by  ovarian  cysts  sit- 
uated above  the  superior  pelvic  strait, 
403. 
intraligamentary    full-term    extrauterine, 

404. 
spontaneous  rupture  of  the  uterus  during, 
20. 

Prostatectomy,  mortality  after,  259. 

Protargol  and  argyrol  as  substitutes  for 
nitrate  of  silver,  29. 

Pruritus  ani,  treatment  of,  365. 

Psychasthenia,  136. 

Psychoses,  organic,  cytodiagnosis  of,  412. 

Pyemia  due  to  middle  ear  operation,  80. 

Pylorus,  hypertrophic  stenosis  of  the,  172. 

R 

Rachitis  and  hydrocephalus  treated  by  radi- 
ant energy,  316. 

Radiant  energy,  hydrocephalus  and  rachitis 
treated  by,  317. 

Radius,  congenital  luxation  of  the  head  of, 
97. 

Reading,  how  a  light  should  be  placed  for, 
222. 

Rectal  surgery,  anesthesia  in,  266. 

Rectum  and  anus,  sterile  water  anesthesia 
in  operative  treatment  of  diseases  of, 
510. 

Renal  calculi,  nephrectomy  for  hydronephro- 
sis due  to,  499. 
colic,  168. 

colic,  artificial,   as  a  valuable  means  of 
diagnosis,  502. 

Respiratory  and  superior  digestive  passages, 
133. 


ARTICLES. 


Reviews  : 

Abdominal  operations,  480. 

A  compound  of  operative  gynecology,  336. 

Acute  contagious  diseases,  143. 

A  laboratory  manual  of  physiological 
chemistry,  ig2. 

A  manual  and  atlas  of  dissection,  432. 

A  treatise  on  diagnostic  methods  of  ex- 
amination, 336. 

A  treatise  on  surgery,  480. 

A  text-book  on  the  practice  of  gynecol- 
ogy, 526. 

Coakley's  laryngology,  47. 

Culbreth's  materia  medica,  528. 

DiflFerential  diagnosis  and  treatment  of 
disease,  238. 

Epitome  of  the  practice  of  medicine,  19a 

Gall-stones  and  their  surgical  treatment, 
288. 

Hare's  text-book  of  practical  therapeutics, 

48. 

International  clinics,  47,  144,  479. 

Nasal  sinus  surgery  with  operations  on 
nose  and  throat,  527. 

Operative  surgery,  143. 

Practical  pediatrics,  96. 

Progressive  medicine,  144,  192,  288,  335, 
576. 

Pulmonary  tuberculosis,  575. 

Self-poisoning  of  the  individual,  95. 

The  physical  examination  of  infantS  and 
young  children,  96. 

The  physician's  visiting  list  for  1907,  576. 

The  practitioner's  visiting  list,  144. 

The  prophylaxis  and  treatment  of  inter- 
nal diseases,  479. 

The  ready  reference  handbook  of  diseases 
of  the  skin,  95. 
Roentgen  ray  measurement,  note  on  the  use 
of  the  milliamper^meter,  512. 


Sclerosis,  multiple,  321. 
Seasickness,  a  specific  for,  323. 
Serum  therapy,  present  status  of,  36. 

therapy,  progress  in,  514. 
Sinusitis,  ethmofrontal,  three  cases  of,  320. 
Sinus,  maxillary,  82. 

thrombosis,  mastoidectomy,  30. 
Skiagraphic  technique,  199. 
Skin,  cancer  of  the,  32. 
Sphincter,  divulsion  of,  and  fissure  in  ani, 
179. 


Spirochaeta  pallida  in  syphilis,  227. 
Stenosis,  hypertrophic,  of  the  pylorus,  173 
Sterility,  the  causes  of,  360. 
Summer  School  of  the  University  of  Mich- 
igan, 446. 
Surgery,  pelvic,  bacteriology  of  peritonitis, 

in  relation  to,  131. 
Surgical  heresy,  18. 

pilgrimage  to  Arkansas,  200. 
Syphilis,  a  study  of,  366. 

hereditary,  influence  of  paternal  inherit- 
ance on,  135. 

spirochaeta  pallida  in,  227. 

treatment  of,  70. 
Syringomyelia  or  leprosy,  74. 


Tendon  transplantation  in  the  forearm,  21. 
Therapeutics  of  lupulin,  229. 
Therapy,  serum,  present  status  of,  36. 

serum,  progress  in,  514. 
Thrombosis,  mastoidectomy  sinus,  30. 

sinus  and  jugular,  symptoms  and  treat- 
ment of,  363. 
Tonsil,  gangrene  of,  134. 
Tonsillitis  and  its  complications,  164. 
Tonsils,  faucial,  lymphatic  drainage  of,  31. 
Tuberculosis  among  school  children,  pre- 
vention of,  318. 

in  children,  origin  of,  ^^. 

of  the  carpus,  214. 

of  the  cervical  lymph  nodes,  24. 

pulmonary,  cocillana  as  an  expectorant  in, 
372. 
Tuberculous  osteitis  of  the  knee,  early  op- 
erative treatment  of,  261. 
Tumor,  cerebral,  mental  symptoms  of,  228. 

of  orbit,  497. 
Tumors,  brain,  84. 

of  the  brain,  563. 
Typhoid  in  children,  504. 

u 

Ulcer,  chronic,  and  gastric  surgery,  313. 

Ulna,  fracture  of,  during  massage  follow- 
ing operation  for  Colles'  fracture,  125. 

Urethral  fistula  and  prolapsed  kidneys,  74. 

Urethra,  the  various  gross  pathological  con- 
ditions of  the,  as  revealed  by  the 
urethroscope,  492. 

Urine,  retention  of,  257. 


ARTICLES. 


Urticaria,  experimental  $tudy  of  some  cases 

of,  510. 
Uterine  efforts  in  parturition,  208. 
Uterus,   anterior  suspension   of   the,   with 
complications  and  secondary  operation, 
471- 
cancer  of,  radical  operation  for,  25. 
spontaneous  rupture  of,  during  pregnancy, 
20. 

V 

Varicose  veins,  215. 

veins  of  the  lower  limb,  22. 
veins,  treatment  of,  219. 


Veins,  varicose,  215. 

varicose,  of  the  lower  limb,  22. 

varicose,  treatment  of,  aigi 
Vertigo,  aural,  564. 
Viscera,  the  weights  of  the,  in  infancy  and 

childhood,  505. 
Visual  fields  as  an  aid  to  diagnosis,  337. 

w 

Warts,    simple,   treatment   of,   by   internal 

remedies,  267. 
Wounds,  corneal,  infection  of,  by  saliva,  264. 


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A  PROFESSIONAL  MEDICAL  JOURNAL. 


VOLUME  XXVIII.  JANUARY,  1906.  NUMBER  I. 


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ORIGINAL  ARTICLES. 


MEMOIRS. 


SOME  NEW  CONCEPTIONS  OF  THE  LIVING  CELL:  ITS 

CHEMICAL  STRUCTURE  AND  ITS  FUNCTIONS.* 

By  victor  C.  VAUGHAN,  Ph.D.,  M. D.,  LL.D.,  Ann  Arbor.  Michigan. 

mOFBSSOR  or  HYGIBKB  and  PHYSIOLOGXCAL  CMBMISTRY,  DIRBCTOIt  OF  THB  HYCIBNIC  ZJkBOBATOBY,  AND 
OBAN  OP  THB  PBPABTMBNT  OF  MBDICINB  AND  SURGBBY  IN  THB  DNIVBRiMTY   OF  MICHIGAN. 

Mr.  Chancellor,  Members  of  the  Faculty,  and  Students:  When  I 
received  from  my  friend,  your  worthy  Dean,  an  invitation  to  address 
you  on  this  occasion,  I  delayed  my  reply  for  some  days,  during  which 
I  seriously  debated  the  question  with  myself.  On  the  one  hand,  the 
memory  of  previous  delightful  visits  to  you  and  the  anticipation  of 
again  being  with  you  urged  me  to  accept ;  while  the  consciousness  that 
I  was  not  prepared  with  an  address  suitable  to  the  occasion,  admonished 
me  that  the  proper  thing  to  do  was  to  decline.  However,  when  I 
recalled  the  indulgence  with  which  you  had  received  my  former  efforts, 
the  decision  was  reached,  and  I  now  have  to  offer  you  my  best,  fully 
conscious  that  it  is  not  good  enough,  and  that  you  will  again  have 
opportunity  to  exercise  your  charity. 

Something  more  than  fifteen  years  have  passed  since  I  had  the 
honor  of  being  the  guest  of  the  University  of  Toronto,  and  I  wish  to 
say  that  it  is  with  great  pleasure  that  I  have  today  seen  the  great 
advance  that  has  been  made  by  this  noble  institution  during  that  time. 
I  first  came  here  to  rejoice  with  my  friend.  Professor  Ramsay  Wright, 
on  the  completion  of  his  biological  laboratory,  and  it  is  a  gratification 
now  to  see  that  this  laboratory  has  more  than  fulfilled  the  promises 
made  at  that  time.  The  research  .work  of  its  eminent  director,  of 
Professor  McCallum,  and  others,  have  carried  the  name  of  the  Univer- 

*  Opening  address  before  the  Medical  Department  of  the  University  of  Toronto, 
October  4,  1905.  Reproduced  by  courtesy  of  The  Canadian  Journal  of  Medicine  and 
Surgery. 


2  ORIGINAL  ARTICLES. 

sity  of  Toronto  around  the  world.  I  have  had  great  pleasure  in  going 
through  his  new  building  with  Professor  Ellis,  and  in  recognizing  that 
a  chemist,  whatever  may  be  the  fate  of  prophets,  is  not  without  honor 
in  his  own  country. 

I  also  rejoice  in  your  splendid  new  Medical  Building,  and  I  envy 
the  freshman  of  today,  who  comes  filled  with  the  earnest  intention  to  do 
his  work  well,  and  who,  under  these  favorable  conditions,  in  the  well- 
equipped  modern  laboratories,  with  such  able  masters  to  direct,  begins 
the  study  of  the  beneficent  science  of  medicine.  I  was  greatly  rejoiced 
on  reading  in  the  papers  this  morning  of  the  munificent  gifts  that  have 
been  made  for  the  new  university  hospital.  Surely  the  people  of 
Toronto  are  both  wise  and  generous.  He  who  aids  in  building  a  hospi- 
tal, where  human  suffering  may  be  relieved,  is  a  practical  Christian, 
whatever  his  theological  dogma  may  be.  We  know  not  whence  we 
came,  nor  can  we  name  the  country  to  which  we  journey,  but  we  do 
know  that  the  burdens  placed  upon  the  shoulders  of  those  who  travel 
along  life's  highway  are  not  equally  distributed,  and  he  who  helps  his 
fellow-man,  who  is  growing  faint,  serves  his  God.  There  is  an  old 
legend  concerning  the  origin  of  the  medical  profession,  which  I  may, 
I  hope,  be  permitted  to  repeat.  It  runs  thus :  In  the  olden  days  when 
the  world  was  yet  young,  a  young  Hindoo  prince,  who  had  all  the  world 
could  give,  entered  a  temple  and,  prostrating  himself  before  the  image 
of  Buddha,  besought  his  god  to  instruct  him  in  the  ways  of  righteous- 
ness. His  prayer  ended,  he  felt  upon  his  shoulder  a  hand  as  light  as 
that  of  a  child,  and  a  voice  as  sweet  as  that  of  an  angel  asked,  "Wouldst 
thou  most  acceptably  serve  thy  God?  If  this  be  thy  desire,  go  forth 
and  serve  thy  fellow-men,"  and  the  prince  went  forth,  the  first  physician 
to  walk  among  men. 

My  visit  is  not  without  its  tinge  of  sadness.  I  miss  several  faces 
that  were  familiar  to  this  campus  fifteen  years  ago.  Of  two  of  these 
I  must  be  permitted  to  say  a  few  words.  There  was  a  sweet-mannefed 
man,  gentle  in  voice  and  kind  even  in  reprimand,  an  eminent  ethnolo- 
gist, an  able  historian,  whose  memory  has  always  been  to  me  a  charming 
recollection.  Such  a  man  was  Sir  Daniel  Wilson.  The  other  was  a 
professional  brother,  whose  life  was  a  help  to  those  of  his  own  genera- 
tion and  an  inspiration  to  the  young.  Such  a  man  was  the  late  Doctor 
Graham,  of  this  city  and  university. 

I  have  decided  to  briefly  discuss  "Some  New  Conceptions  of  the 
Living  Cell :  Its  Chemical  Structure  and  Its  Functions."  No  one  can 
question  the  importance  of  this  subject,  involving,  as  it  does,  biological 
problems,  which  lie  at  the  foundation  of  all  our  conceptions  and  theories 
concerning  cellular  life  and  cellular  activity. 

To  start  ab  initio,  the  cell  is  made  up  of  matter,  and  the  newer 
views  on  matter  must  be  taken  into  consideration  in  formulating  a 
conception  of  the  cell.  When  matter  becomes  endowed  with  life  it  does 
not  cease  to  be  matter ;  it  does  not  lose  ijs  inherent  properties ;  it  is  not 
released  from  the  laws  that  govern  its  structure,  its  attractions,  and  its 


CONCEPTIONS  OF  THE  LIVING  CELL.  3 

motions.  In  studying  the  organized  cell  of  living  thing,  whether  vege- 
table or  animal,  it  should  always  be  borne  in  mind  that  it  is  material  in 
composition  and  subject  to  the  fundamental  laws  that  govern  matter, 
and  possessed  of  those  properties  essential  to  matter.  In  order  that 
this  point,  so  essential  to  a  proper  understanding  of  the  subject,  should 
be  thoroughly  appreciated,  it  may  be  best  to  recall  some  of  the  prop- 
erties of  matter  as  taught  by  the  most  advanced  science  of  the  day. 

Tait  says :  "Matter  is  that  which  can  be  perceived  by  the  senses,  or 
is  that  which  can  be  acted  upon  by  or  can  exert  force."  Since  force  is 
the  restilt  of  motion,  we  may  say  that  anything  and  everything  that 
moves  or  can  be  moved,  or  whose  position  in  space  may  be  changed  is 
matter.  There  are  many  forms  of  matter  that  cannot  be  seen  or  felt, 
and  can  be  recognized  only  by  their  motions. 

Matter  is  indestructible;  it  may  be  successively  solid,  liquid  and 
gas,  but  in  undergoing  these  changes  it  neither  gains  nor  loses.  It  has 
always  been,  and  it  always  will  be.  It  is  without  beginning  and  will  be 
without  end.  Matter  consists  of  infinitely  small  particles,  called  atoms. 
According  to  tlje  computation  of  Lord  Kelvin,  the  diameter  of  an  atom 
is  not  greater  than  a  1-50,000,000  of  an  inch ;  however,  all  atoms  are  not 
of  the  same  size  or  weight.  When  like  atoms  combine  they  form 
chemical  elements,  of  which  about  seventy  are  known.  The  hydrc^en 
atom  is  the  lightest  of  all  known  elements,  and  it  therefore  is  taken 
as  the  base  or  standard  in  the  determination  of  atomic  weights.  When 
unlike  atoms  combine,  chemical  compounds  are  formed,  and  the  number 
of  these  is  beyond  computation.  It  was  supposed,  until  the  discovery 
and  study  of  radium,  that  one  chemical  element  is  never  converted  into 
another,  and  consequently  that  the  number  of  kinds  of  atoms  is  fixed 
and  unchangeable.  However,  it  has  been  found  that  the  ;ir-rays  of 
radium  consist  of  most  minute  particles,  which,  when  confined  in  glass, 
condense  and  form  another  element,  helium.  With  this  demonstration 
of  the  formation  of  one  element  from  another  it  is  within  the  range 
of  sanity  to  suppose  that  all  the  elements  have  been  developed  from 
a  primordial  ancestor,  probably  from  the  universal  ether  which  per- 
vades all  space..  Nothing  has  been  created;  everything  has  grown. 
Even  silver,  iron,  and  other  metals  came  into  existence  by  being  cast 
off  from  some  common  ancestral  element.  The  atomic  weight  of 
radium  is  225  and  that  of  helium  2.02.  It  would  seem  from  this  that 
an  atom  of  the  former  breaks  up  into  about  one  hundred  atoms  of  the 
latter,  and  in  this  way  a  new  element  is  bom,  although  in  this  case  it 
is  probable  that  the  mother  atom  is  split  into  two  or  more  kinds.  It 
will  be  seen  from  this  that  even  atoms  may  be  split  up.  Indeed,  there 
are  reasons  for  believing  that  the  hydrogen  atom  consists  of  a  nuclear 
ion  about  which  some  seven  hundred  particles  or  electrons  revolve,  and 
an  atom  of  mercury  is  believed  to  consist  of  not  less  than  one  hundred 
thousand  electrons.  Atoms  and  electrons  are  in  constant  motion,  and 
so  small  are  they  that  the  distances  between  them  may  be  relatively 
as  great  as  those  between  the  planets  of  the  solar  system.    The  living 


4  ORIGINAL  ARTICLES. 

cell  is  c(»iiposed  of  molecules,  made  up  of  atoms,  composed  of  electrons 
that  are  in  constant  and  systematic  motion,  and  may  be  compared  to  a 
group  of  stars  with  attendant  suns,  each  of  which  is  surrounded  by  its 
own  planets.     A  molecule  of  albumin  is  of  like  composition. 

Another  property  of  matter  is  that  it  is  gravitative.  Every  particle 
of  matter  attracts  every  other  particle.  When  this  attraction  is  mani- 
fest between  masses  it  is  called  gravitation;  between  molecules,  it  is 
called  cohesion  or  adhesion,  as  the  molecules  held  together  are  alike 
or  unlike;  between  atoms  it  is  known  as  chemical  affinity  or  chemism. 

Still  another  property  of  matter  is  inertia,  by  which  term  we  indi- 
cate the  inability  of  matter  to  change  either  its  rate  or  direction  of 
motion  without  being  acted  upon  by  other  matter.  It  is  of  great 
importance  that  this  property  of  matter  be  held  in  mind  in  the  study 
of  cellular  chemistry,  and  the  proper  mental  picture  of  a  cell  molecule 
represents  each  of  the  atoms  in  the  molecule,  and  each  electron  in  each 
atom  moving  each  about  its  centre  and  each  at  a  definite  rate.  If 
such  a  cell  molecule  could  be  cut  off  permanently  from  the  disturbing 
influence  of  other  matter,  its  atoms  and  electrons  would  continue  the 
same  motions,  unchanged  in  direction  or  rate,  throughout  eternity, 
but,  as  we  shall  later  see,  it  would  be  impossible  for  living  matter  to 
continue  to  live  apart  from  other  matter.  Within  the  living  cell 
molecule  change  in  number,  kind,  and  arrangement  of  atoms  is  con- 
stant ;  and  the  direction  ^nd  rate  of  the  motion  of  the  atoms  are  also 
susceptible  to  the  influence  of  other  matter  and  are  of  constant 
occurrence.  Whole  groups  of  atoms  are  physiologically  being  dropped 
from  the  cellular  molecule  and  being  replaced  by  other  groups  split 
oflF  from  the  pabulum  upon  which  the  cell  feeds.  In  this  way  the 
cell  renews  itself  and  keeps  itself  supplied  with  energy. 

Some  of  the  most  noted  physicists  are  inclined  to  the  belief  that 
matter  is  made  up  of  electric  charges,  but  recognize  that  this  is  not  a 
demonstrated  fact  as  yet,  and  speak  with  caution.  Lodge  says: 
"There  may  possibly  be  two  diflFerent  kinds  of  inertia,  which  exactly 
simulate  each  other,  one  electrical  and  the  other  material;  and  those 
who  hold  this  as  a  reasonable  possibility  are  careful  to  speak  of  electrons 
as  'corpuscles,'  meaning  charged  particles  of  matter  of  extremely  small 
size,  much  smaller  than  an  atom,  consisting  of  a  definite  electric  charge 
and  an  unknown  material  nucleus;  which  nucleus,  as  they  recognize, 
but  have  not  yet  finally  proved,  may  quite  possibly  be  zero." 

The  only  essential  and  constant  difference  between  living  and 
nonliving  matter  is  that  within  the  molecules  of  the  former  there  is 
constant  metabolism,  while  in  the  latter  no  such  process  occurs.  We 
are  to  conceive  of  the  living  molecule  as  made  up  of  numerous  atoms 
and  each  atom  surrounded  by  its  electrons:  atoms  and  electrons  in 
ceaseless  motion,  and  groups  of  atoms  being  constantly  cast  out  of 
the  molecule  and  replaced  by  new  groups  split  off  from  matter  outside 
the  molecule.  As  soon  as  a  molecule  becomes  the  seat  of  assimilation 
and  excretion,  it  is  no  longer  dead,  it  lives.     As  a  result  of  assimilation 


CONCEPTIONS  OF  THE  LIVING  CELL.  5 

it  acquires  the  property  of  building  up  its  own  tissue ;  then  polymeriza- 
tion follows  and  reproduction  in  its  simplest  form  begins.  The  one 
phenomenon  always  manifested  by  living  matter,  and  never  exhibited 
by  nonliving  matter,  is  metabolism.  Verworm  says:  "Vital  motion, 
metabolism,  is  a  complex  motion  very  strongly  characterizing  the  living 
organism ;  it  consists  in  the  continual  self-decomposition  of  living  sub- 
stance, the  giving  off  to  the  outside  of  the  decomposition  products, 
and,  in  return,  the  taking  in  from  the  outside  of  certain  substances 
which  give  to  the  organism  the  material  with  which  to  regenerate 
itself  and  grow  by  the  formation  of  similar  groups  of  atoms,  that  is, 
by  polymerization.     This  is  characteristic  of  all  living  substance." 

I  have  promised  to  give  you  some  of  the  new  conceptions  of  the 
living  cell,  and  yet  I  must  admit  that  Aristotle  apparently  recognized 
that  metabolism  is  the  one  characteristic  of  living  matter,  for  he  says : 
"Life  is  the  assemblage  of  the  operations  of  nutrition,  growth  and 
destruction."  Of  course,  this  Greek  philosopher  did  not  know  about 
cells,  molecules,  atoms  and  electrons  what  is  today  known,  but  it  must 
be  acknowledged  that  he  had  a  clear  conception  of  the  most  essential 
characteristics  of  living  matter.  Herbert  Spencer  has  given  three 
definitions  of  life,  and  either  may  be  applied  to  the  conception  which 
I  am  trying  to  present  to  you.  The  first  is :  "Life  is  the  coordination 
of  actions."  The  coordination  between  assimilation  and  excretion  is 
certainly  essential  to  life,  and  failure  of  this  coordination  leads  to 
death.  The  second  is  probably  the  best  definition  of  life  ever  given, 
and  fits  our  conception  perfectly.  It  is:  "Life  is  the  definite  com- 
bination of  heterogeneous  changes,  both  simultaneous  and  successive, 
in  correspondence  with  external  coexistences  and  sequences."  The 
third  is  practically  the  same  as  the  second,  expressed  in  simpler  terms, 
but  in  my  opinion  not  so  satisfactorily.  It  reads:  "Life  is  the  con- 
tinuous adjustment  of  internal  relations  to  external  relations."  Matter 
is  alive  when  it  feeds  and  excretes.  Crystals  grow  and  in  a  sense  they 
multiply,  but  their  growth  is  not  intramolecular,  it  is  by  accretion. 
The  living  molecule  not  only  absorbs,  it  assimilates.  It  chemically 
alters  what  it  absorbs.  The  atomic  groups  taken  into  the  living  mole- 
cule enter  into  new  combinations.  The  living  molecule  is  not  stable, 
but  is  highly  labile.  Its  composition  is  never  constant  and  it  is  never 
in  a  condition  of  equilibrium.  There  is  a  constant  reaction  between 
the  living  molecule  and  other  molecules.  Apart  from  other  matter 
it  could  not  exist.  There  is  a  constant  interchange  of  atones  between 
it  and  other  molecules.  A  condition  best  designated  as  latent  life 
may  exist  without  interchange  of  atoms  between  molecules.  This  is 
seen  in  spores,  s^eds  and  ova.  Matter  existing  in  this  form  may  be 
awakened  into  activity  by  proper  stimuli;  active  life  begins  with  the 
interchange  of  atoms. 

Why  is  there  this  constant  atomic  group  Interchange  between  the 
living  molecule  and  outside  matter?  It  is  for  the  purpose  of  supplying 
the  living  molecule  with  energy.     Allen  has  so  ably  expressed  this 


6  ORIGINAL  ARTICLES. 

fact  that  I  make  the  following  quotation:  "The  most  prominent  and 
perhaps  most  fundamental  phenomenon  of  life  is  what  may  be  described 
as  the  ettergy  traffic  or 'the  function  of  trading  in  energy.  The  chief 
physical  function  of  living  matter  seems  to  consist  in  absorbing  energy, 
storing  it  in  a  higher  potential  state,  and  afterwards  partially  expending 
it  in  the  kinetic  or  active  form.  We  find  in  living  matter  a  peculiar 
proneness  to  change  its  composition  under  the  stimulus  of  slight 
changes  in  the  energy-equilibrium  between  itself  and  its  surroundings, 
energy  being  readily  absorbed  and  readily  dispersed.  The  absorption 
of  energy  coincides  with  deoxidation  and  the  building  of  large  mole- 
cules ;  conversely  the  dispersion  of  energy  coincides  with  oxidation  and 
the  disruption  of  the  large  molecules.  The  building  of  these  large 
molecules  is  always  accomplished  by  slow  steps ;  but  when  formed,  the 
said  molecules  are  very  unstable,  irritable,  or  in  modern  phrase,  labile. 
They  may  break  down  by  degrees  in  some  instances;  in  others  their 
structure  may  be  so  precarious  as  to  collapse  on  the  slightest  disturb- 
ance." 

"The  lability  of  such  a  molecule  may  be  compared  to  that  of  a 
house  of  cards,  which  can  be  taken  to  pieces,  card  by  card,  or  may 
collapse  at  once.  But  the  word  lability  is  applied,  not  only  to 
d^-structive,  but  also  to  con-structive  instability.  The  molecules  of 
living  substance  are  prone  to  constructive  as  well  as  destructive 
changes;  but,  as  in  the  house  of  cards,  the  constructive  changes  are 
the  most  gradual;  and  as  the  structure  grows  more  complex,  con- 
struction becomes  more  difficult,  and  collapse  is  more  imminent.  It 
should  be  distinctly  understood,  however,  that  it  is  not  the  mere  size 
of  the  molecules  that  makes  them  labile,  but  rather  the  manner  in 
which  they  are  linked  together,  and  the  amount  of  potential  energy 
which  is  included  in  the  molecule." 

It  is  probable  that  in  the  absorption  of  energy  by  the  living  mole- 
cule, oxygen  is  relieved  from  its  combination  with  carbon  or  hydrogen 
and  is  attached  to  nitrogen,  while  in  the  liberation  of  energy  the 
reverse  takes  place.  Nitrogen  and  phosphorus,  sometimes  with  iron 
and  possibly  manganese,  seem  to  be,  as  it  were,  the  master  elements 
within  the  living  molecule.  It  is  by  virtue  of  their  chemism  that  groups 
are  torn  from  extracellular  matter,  taken  into  the  living  molecule  and 
assimilated  by  an  atomic  rearrangement;  and  furthermore,  it  is  on 
account  of  the  lability  of  the  compound  thus  formed  that  potential 
energy  is  converted  into  kinetic  and  cell  work  is  accomplished. 

The  question  of  the  origin  of  life  on  this  world  has  been  ably  dis- 
cussed by  eminent  chemists,  physicists  and  biologists.  The  cosmozoa 
theory  proposed  by  Richter  holds  that  cellular  life  has  always  existed, 
and  has  been  transferred  from  one  planet  to  another  by  meteors  and 
cosmic  dust.  Richter  says:  ''Omne  vivum  ab  aeternitate  e  cellula." 
Helmholtz  and  Lord  Kelvin  have  pronounced  this  theory  not  unscien- 
tific, and  the  former  makes  the  following  statement :  "Meteoric  stones 
sometimes  contain  hydrocarbon  compounds;  the  intrinsic  light  of  the 


CONCEPTIONS  OF  THE  LIVING  CELL.  7 

heads  of  comets  shows  a  spectrum  that  is  very  similar  to  that  of  the 
incandescent  electric  light  in  gases  containing  hydrocarbon.  But 
carbon  is  the  characteristic  element  of  the  organic  compounds,  of  which 
living  bodies  are  composed.  Who  can  say  whether  these  bodies  that 
swarm  everywhere  through  space  do  not  spread  also  the  germs  of  life 
whenever  a  new  world  has  become  capable  of  affording  a  dwelling- 
place  to  organic  creatures?  And  this  life  we  mig^t,  perhaps,  have 
reason  to  regard  as  even  allied  to  our  own  in  germ,  however  various 
may  be  the  forms  in  which  it  might  adapt  itself  to  the  conditions  of  its 
new  dwelling-place." 

Preyer  objects  to  the  cosmozoa  theory  that  it  only  sets  the  question 
back  to,  How  did  life  originate  in  the  universe :  and  Helmholtz  says : 
"The  true  alternative  is  evident ;  organic  life  has  either  begun  to  exist 
at  some  one  time,  or  has  existed  from  eternity." 

Pfliiger's  theory  of  the  origin  of  life  is  the  most  scientific  yet 
proposed.  He  argues  that  living  proteid  differs  from  dead  proteid  by 
the  existence  in  the  former  of  a  cyanogen  radicle.  He  says :  "In  the 
formation  of  cell  substance,  that  is,  of  living  proteid  out  of  food  proteid, 
a  change  of  the  latter  takes  place,  the  atoms  of  nitrogen  going  into  a 
cyanogen-like  relation  with  the  atoms  of  carbon,  probably  with  the 
absorption  of  considerable  heat."  Pfliiger  calls  attention  to  the  resem- 
blances between  cyanic  acid,  HCNO,  and  living  proteid.  Both  easily 
polymerise,  the  living  proteid  growing  and  the  cyanic  acid  forming 
the  polymeric  cynamelid  HnOwNnOw.  Both  yield  urea  on  dissocia- 
tion; both  are  liquid  and  transparent  at  low  temperature,  and  both 
coagulate  at  higher  temperature.  Pfliiger  concludes  that  the  beginning 
of  life  depended  upon  the  formation  of  cyanogen,  and  then  he  reminds 
us  that  cyanogen  and  its  compounds  are  produced  only  at  incandescent 
heat.  He  summarizes  as  follows:  "Accordingly,  I  would  say  that 
the  first  proteid  to  arise  was  living  matter,  endowed  in  all  its  radicles 
with  the  property  of  vigorously  attracting  similar  constituents,  adding 
them  chemically  to  its  molecule,  and  thus  growing  ad  infinitum. 
According  to  this  idea,  living  proteid  does  not  need  to  have  a  constant 
molecular  weight;  it  is  a  huge  molecule  undergoing  constant,  never- 
ending  formation  and  constant  decomposition,  and  probably  behaves 
towards  the  living  chemical  molecules  as  the  sun  behaves  towards 
small  meteors."* 

It  will  be  seen  that  according  to  Pfliiger  life  is  a  molecular  phe- 
nomenon, and  it  seems  to  be  that  this  must  be  true.  Nonliving  matter, 
whether  it  be  inorganic  or  organic,  is  relatively  stable  intramolecularly, 
while  living  matter  is  never  stable  within  its  molecule,  which  is  con- 
stantly casting  out  and  as  constantly  absorbing  atomic  groups.  It 
assimilates  and  it  excretes,  and  these  phenomena  are  its  essentials. 
Deprive  the  living  molecule  of  food,  and  it  dies ;  prevent  its  excretion, 
and  it  dies.  Reaction  between  the  living  molecule  and  outside  matter 
is  constant,  and  is  necessary  to  the  continuance  of  life.    The  fact  that 

"The  different  theories  of  the  origin  of  life  are  ably  discussed  by  Verworm  in  his 
"General  Physiology." 


8  ORIGINAL  ARTICLES. 

life  resides  in  the  molecule  is,  as  I  have  stated,  taught  in  Pfliiger's 
theory.  It  is  also  recognized  by  Allen,  who,  in  speaking  of  living 
proteid,  says:  "It  is  a  molecule  of  enormous  size,  and  (so  far  as  the 
dynamic  elements  are  concerned)  its  various  groups  are  linked  together 
by  many  nitrogen  atoms,  but  not  in  a  chain.  It  is  not  a  proteid,  a 
cyan  compound,  an  amid,  an  amine,  nor  an  alkaloid,  but  something 
that  can  yield  some  of  them  during  life  and  others  at  its  death.  Death 
consists  in  the  relaxation  of  the  strained  relationship  of  the  nitrogen 
to  the  rest  of  the  molecule.  When  thus  'the  silver  cord  is  loosened/ 
the  relaxed  groups  fall  into  a  state  of  repose.  Most  of  these  groups 
are  proteids  in  which  the  N  is  peripheral,  triad  and  unoxidized,  having 
yielded  its  O  to  some  other  element.  If,  however,  such  a  proteid 
molecule  be  applied  to  a  living  cell,  it  can  be  linked  on  again  by  its  N, 
which  thus  once  more  becomes  central." 

In  his  very  interesting  monograph  on  the  "Biogen  Hypothesis," 
Verworm  objects  to  saying  that  a  molecule  lives.  He  states  that  it  is 
illogical.  "A  living  thing  is  only  that  which  demonstrates  the  phe- 
nomenon of  life — something  that  changes  itself.  A  molecule  of  a 
given  compound,  so  long  as  it  remains  unchanged,  cannot  be  said  to 
be  living."  Then,  in  order  not  to  speak  of  living  molecules,  he  intro- 
duces the  term  "biogen  molecule,"  instead  of  the  living  molecule. 
Surely  this  is  a  distinction  without  a  difference.  I  certainly  agree  that 
a  molecule  of  a  germ  compound,  so  long  as  it  remains  unchanged, 
cannot  be  said  to  be  living,  but  the  point  is  that  living  molecules  do  not 
remain  unchanged.  When  life  is  latent,  as  it  is  in  seeds  and  spores, 
the  molecules  cannot  be  said  to  be  alive ;  but  when  placed  under  suitable 
conditions,  then  the  change  between  atomic  groups  in  the  molecule 
and  the  external  food  substance  begins,  and  life  first  manifests  itself. 
However,  it  matters  but  little,  I  suppose,  whether  we  speak  of  living 
molecules  or  biogen  molecules. 

That  life  resides  within  the  molecule  and  that  metabolic  processes 
are  intramolecular,  are  shown  by  numerous  investigations,  some  of  the 
most  important  of  which  may  be  briefly  stated  as  follows : 

(i)  As  long  ago  as  1867  it  was  shown  by  Hermann,  in  his  studies 
on  the  metabolism  of  isolated  muscle,  that  the  carbonic  acid  and  lactic 
acid  that  are  formed  by  muscular  contraction  result  from  the  action 
of  intramolecular  or  combined  oxygen.  This  was  demonstrated  by 
the  fact  that  when  a  muscle  was  freed  from  all  its  uncombined  oxygen 
under  an  air  pump  and  then  caused  to  contract  in  an  oxygen-free 
medium,  it  gives  off  carbonic  and  lactic  acids.  Contraction,  a  vital 
muscle  phenomenon,  is  thus  shown  to  result  from  intramolecular 
changes. 

(2)  In  1875,  Pfliiger  kept  a  frog  at  a  temperature  of  a  few  degrees 
above  zero  in  an  atmosphere  free  from  oxygen  for  twenty-five  hours, 
and  found  that  during  that  time  the  animal  continued  to  give  off  car- 
bonic acid.  From  this  Pfliiger  concluded  that  the  living  content  of  the 
organism  consists  of  proteid,  which  he  designates  "living  proteid,"  in 


CONCEPTIONS  OF  THE  LIVING  CELL.  9 

contradistinction  to  dead  proteid,  and  that  the  carbonic  acid  gas  results 
from  the  decomposition  of  a  labile  proteid  molecule,  the  nitrogehous 
constituents  of  which  are  capable,  with  the  help  of  the  fats  and  car- 
bohydrates of  the  food,  to  regenerate  "the  living  proteid  molecule." 

(3)  It  has  been  shown  by  recent  research  in  my  own  laboratory 
that  both  the  toxin  and  the  carbohydrate  of  the  cell  of  the  colon  bacillus 
are  held  in  chemical  combination  with  other  constituents  of  the  cell. 
This  microorganism  will  grow  in  a  medium  which  contains  organic 
nitrogen,  as  amino  compound  only,  and  with  this  nitrogen  and  inor- 
ganic salts  as  its  sole  food,  it  builds  up  by  synthetical  process  a  complex 
glyco-nucleo-proteid,  forming  a  large  molecule  which  contains  as 
atomic  groups,  pentose,  nuclein  bases,  amino  and  diamino  compounds. 
These  constituents  are  held  chemically  in  the  cell.  They  cannot  be 
washed  out  by  physical  solvents,  and  can  be  isolated  only  by  chemically 
breaking  down  the  cell  molecule. 

Besides  the  above-mentioned  experimental  data  showing  that  life 
manifests  itself  by  intramolecular  reaction,  the  following  general  con- 
siderations indicate  the  same  thing: 

(a)  In  taking  its  food  the  cell,  whether  it  be  vegetable  or  animal, 
whether  it  be  that  of  a  unicellular  or  that  of  a  multicellular  organism, 
manifests  a  selective  action  which  can  be  best  explained — indeed,  I 
might  say,  can  only  be  explained — on  the  ground  that  it  is  due  to 
chemical  affinity.  Mass  and  molecular  attractions  are  not  specific, 
while  atomic  attraction,  or  chemical  affinity,  as  it  is  usually  designated, 
is  specific,  or  at  least  selective.  This  fact,  as  is  well  known,  is  the 
basis  of  the  side  chain  theory  of  Ehrlich,  who,  upon  this  principle, 
explains  the  nutrition  of  cells,  the  action  of  many  therapeutical  agents 
and  the  production  and  action  of  antitoxins.  It  is  well  known  that 
certain  poisons  have  a  selective  action  for  certain  tissues,  and  this 
means  that  the  chemical  affinity  between  the  poison  and  the  con- 
stituents of  certain  cells  is  greater  than  that  between  this  poison  and 
other  cells.  If  pharmacology  and  toxicology  ever  become  exact 
sciences  it  will  be,  most  probably,  through  investigations  directed  along 
this  line. 

(b)  The  fact  that  the  secretions  of  cells  are  specific  is  a  strong 
argument  for  the  theory  that  action  on  the  pabulum  upon  which  they 
feed  is  intramolecular.  The  liver  cells  produce  bile  pigments  and 
acids,  each  of  the  digestive  fluids  elaborates  its  specific  products,  the 
specific  secretions  of  the  adrenals  and  the  thyroid  gland  have  been 
studied  and  are  now  largely  and  successfully  employed  therapeutically. 
And  still  all  these  organs  are  supplied  with  the  same  blood  and  lymph. 
Certainly  the  only  possible  explanation  for  these  well-established  facts 
is  that  of  a  chemical  reaction,  or  an  intramolecular  reaction,  between  the 
cells  and  the  constituents  of  the  substances  with  which  they  are  brought 
into  contact. 

While  other  arguments  might  be  adduced  to  show  that  metabolic 
processes,  the  only  phenomena  with  which  we  are  acquainted,  that  are 
characteristic  of  all  living  matter  and  which  do  not  occur  in  dead  mat- 


10  ORIGINAL  ARTICLES. 

ter,  are  due  to  intramolecular  reactions,  it  seems  to  me  that  those 
alr&idy  given  are  sufficient  to  establish  my  thesis,  that  is,  life  is  mole- 
cular. 

If  I  have  made  good  my  contention  so  far,  it  follows  that  life  begins 
with  the  first  molecule  that  is  endowed  with  the  capability  of  growth 
and  reproduction.  The  life  of  such  a  molecule  would  depend  upon  its 
continued  reaction  with  matter  outside  of  itself,  or,  in  other  words,  it 
must  feed;  and  reproduction  in  its  simplest  form  would  depend  upon 
polymerization.  In  this  way  the  wonderful  experiments  of  Loeb  upon 
the  artificial  fertilization  of  certain  ova  are  easily  explained.  The  ovum 
is  not  alive;  it  possesses  only  latent  life,  and  when  acted  upon  by 
certain  stimuli  it  begins  active  life.  This  stimulus  may  be  a  spermata- 
zoon  or  some  inorganic  salt  in  a  certain  definite  strength  of  solution. 

If  life  be  molecular,  it  is  possible  that  its  lowest  manifestations  are 
without  form.  They  may  be  infinitely  small,  and  it  is  not  beyond  the 
range  of  possibility  that  they  may  exist  as  solids,  liquids,  or  gases. 

Spontaneous  generation  has  never  been  proved  to  be  impossible; 
indeed,  it  will  not  be  eas^  to  disprove  spontaneous  generation.  I  agree 
with  Naegele  in  the  following  statement:  "One  fact — ^that  in  or- 
ganisms inorganic  substance  becomes  organic  substance,  and  that  the 
organic  returns  completely  to  the  inorganic — is  sufficient  to  enable 
us  to  deduce  by  means  of  the  law  of  causation  the  spontaneous  origin 
of  organic  nature  from  inorganic.  ...  If  in  the  physical  world  all 
things  stand  in  causal  connection  with  one  another,  if  all  phenomena 
proceed  along  natural  paths,  then  organisms,  which  build  themselves 
up  from  and  finally  disintegrate  into  the  substances  of  which  inorganic 
nature  consists,  must  have  originated  primitively  from  inorganic  com- 
pounds.    To  deny  spontaneous  generation  is  to  proclaim  a  miracle." 

The  experiments  of  Tindall,  Pasteur,  and  others,  which  were  sup- 
posed to  completely  and  forever  overthrow  the  doctrine  of  spontaneous 
generation,  in  my  humble  opinion,  did  no  such  thing.  They  simply 
demonstrated  that  bacteria  do  not  spontaneously  generate  in  meat 
infusions  and  similar  media,  nothing  more.  Now,  it  seems  to  me  that 
bacteria,  which  we  frequently  call  the  lowest  forms  of  life,  are  by  no 
means  certainly  entitled  to  this  distinction.  They  may  be  the  lowest 
forms  with  which  we  are  acquainted,  the  smallest  living  things  that 
we  can  see  with  our  best  microscopes.  But  chemically  they  are  com- 
posed of  extremely  complex  molecules,  as  has  been  shown  by  recent 
research  in  my  laboratory.  As  I  have  already  stated,  the  cell  of  the 
colon  bacillus  consists  of  a  highly  complex  glyco-nucleo-proteid,  yield- 
ing, on  chemical  disintegration,  a  carbohydrate,  pentose,  the  nuclein 
bases,  the  monamino  and  diamino  bodies,  as  tyrosin,  leucin,  lysin  and 
arginin.  In  other  words,  chemically  the  colon  molecule  is  quite  as 
complex  as  that  of  the  lower  grade  tissues  in  man.  Now,  if  there  has 
been  a  chemical,  as  well  as  a  morphological,  evolution,  the  colon  bacillus 
is  not  the  lowest  form  of  life;  indeed,  it  must  be  far  removed  from  the 
first  molecule  that  manifested  metabolic  activity. 


CONCEPTIONS  OF  THE  LIVING  CELL.  11 

The  following  quotation  from  Nussbaum,  as  given  by  Loeb,  shows 
that  the  biologist  recognizes  that  the  cell  is  not  the  unit  of  life :  "The 
cell  is  not  the  ultimate  physiologic  unit,  even  though  it  must  remain 
such  for  the  morpholc^st.  We  are,  however,  not  able  to  tell  how  far 
the  divisibility  of  a  cell  goes,  and  how  we  can  determine  the  limit 
theoretically.  Yet  for  the  present  it  will  be  well  not  to  apply  to  living 
matter  the  conceptions  of  atoms  and  molecules,  which  are  well  defined 
in  physical  chemistry.  The  notion,  micella,  introduced  by  Naegele, 
might  also  lead  to  difficulties,  as  the  properties  of  living  matter  are 
based  upon  both  nuclein  and  protoplasm.  .  .  .  The  cell,  conse- 
quently, represents  a  multiple  of  individuals." 

Pfliiger  has  shown  that  the  egg,  which  has  been  thought  to  be  a 
unit,  can  give  rise  to  many  individuals,  and  Loeb  states  that  his  own 
experiments,  as  well  as  those  of  Driesch,  confirm  this  finding. 

It  is  highly  probable  that  the  lowest  forms  of  life  cannot  feed  upon 
proteids.  This  is  true  of  the  yeast  cell.  These  cells  grow  rapidly 
when  placed  in  a  solution  of  sugar  and  nitrates,  but  proteids  must  be 
broken  up  by  putrefactive  bacteria  before  the  yeast  germs  can  feed  upon 
them.  Indeed,  many  of  the  cells  of  the  body  of  man  cannot  feed  upon 
proteids,  which  must  be  split  up  by  the  digestive  enzymes  into  much 
smaller  and  simpler  groups  before  the  cell  molecules  can  assimilate 
them.  Even  the  carbohydrate,  starch,  must  be  hydrated  before  it  can 
become  a  source  of  energy  in  muscle.  Proteid  solutions  injected  into 
the  blood  of  man  are  poisonous,  but  the  same  substance,  after  being 
properly  split  up,  is  an  essential  cell  food.  There  are  weighty  reasons 
for  believing  that  proteid  is  not  produced  by  the  lowest  forms  of  life. 
However,  as  proteid,  or  cellular  life,  is  the  only  form  of  life  that  we 
know,  it  would  be  quite  useless  to  attempt  to  go  further  along  this 
line. 

I  have  probably  said  enough  concerning  spontaneous  generation 
to  bring  down  upon  myself  the  anathemas  of  the  orthodox  in  science, 
and  since  my  opinion  on  this  subject  does  not  have  any  essential  rela- 
tion to  the  important  thesis  of  this  paper,  I  will  leave  this  point  without 
further  discussion. 

If  the  characteristic  phenomena  of  life  are  due  to  intramolecular 
reactions,  we  must  conceive  the  living  cell,  whether  it  belong  high  or 
low  in  the  scale  of  development,  as  consisting  in  its  essential  or  vital 
part  of  a  chemical  compound  made  up  of  complex  molecules,  composed 
of  atoms,  each  surrounded  by  its  electrons,  all  in  motion,  and  with  a 
constant  absorption  of  atomic  groups  from  other  molecules,  and  whh 
a  like  constant  casting  off  of  atomic  groups. 

This  molecule  feeds  by  splitting  off  such  groups  as  it  may  need 
from  the  pabulum  within  its  reach,  or  it  may  absorb  whole  molecules, 
at  the  same  time  rearranging  the  atoms  and  making  them  a  part  of 
itself. 

When,  in  ordinary  physiological  function,  a  portion  of  this  molecule, 
which  we  may  designate  its  chemical  nucleus,  remains  undisturbed  and 


12  ORIGINAL  ARTICLES. 

regenerates  the  whole,  supplying  its  waste  by  the  absorption  of  new 
matter. 

Cellular  assimilation  consists  in  properly  locating  the  recently 
acquired  groups  within  the  molecule. 

Certain  cell  molecules,  under  proper  stimuli,  rearrange  their  atomic 
grouping,  polymerise,  and  thus  multiply.  This  multiplication  may  be 
physiolc^cal  or  pathological.  Rapid  proliferation  may  tend  to  inability 
to  function  or  to  react  with  the  food  supply,  and  consequently  destroy 
the  molecule  or  lead  to  the  death  of  the  cell. 

With  this  conception  of  a  living  cell,  its  secretions  consist  of  the 
atomic  groups  cast  out  as  a  result  of  its  reactions  with  external  matter, 
and  as  the  cells  of  different  organs  are  unlike  in  their  chemical  com- 
position, it  follows  that  the  secretions  are  specific.  Outside  the  body 
hemoglobin  breaks  up,  or  may  be  broken  up,  chemically,  into  hematin 
and  globulin.  In  this  case  the  colored  split  product  contains  the  iron. 
But  the  liver  cells  produce  from  hemoglobin  bilirubin  and  an  iron 
containing  proteid.  In  this  inaction  the  line  of  cleavage  is  quite  dif- 
ferent from  that  followed  in  the  ordinary  decomposition  of  hemoglobin. 
The  secretions  of  some  cells  enter  into  a  more  or  less  energetic  reaction 
with  certain  extra-cellular  compounds  with  which  they  come  in  con- 
tact. This  is  true  of  the  digestive  enzymes.  Other  secretions  appar- 
ently are  made  for  the  purpose  of  reacting  with  or  at  least  affecting 
the  reactions  of  the  molecules  of  other  cells.  This  seems  to  be  true  of 
some  at  least  of  the  so-called  internal  secretions,  such  as  those  of  the 
thyroid  and  adrenals. 

A  most  important  group  of  cellular  secretions  is  made  up  of  the 
ferments  of  enzymes.  Without  going  into  the  history  of  the  theories 
that  have  been  advanced  concerning  the  nature  of  these  bodies,  it  seems 
to  me  that  we  are  no  longer  justified  in  speaking  of  "organized  and 
unorganized"  ferments.  All  the  ferments  are  cellular  products.  The 
work  of  Buchner  on  the  ferment  of  the  yeast  plant  seems  to  be  posi- 
tively convincing  on  this  point.  Oppenheimer  has  defined  a  ferment 
in  a  manner  that  seems  to  me  to  be  quite  in  accord  with  the  latest  and 
best  experimental  investigation.  His  definition  is  as  follows :  "A  fer- 
ment is  a  catalytically-acting  substance  which  is  produced  by  living 
cells,  to  which  it  is  more  or  less  firmly  bound,  whilst  its  action  is  not 
associated  with  the  vital  processes  of  the  cells  (which  produce  it)  ; 
ferments  are  capable  of  inaugurating  chemical  processes  which  take 
place  spontaneously  (without  the  presence  of  the  ferments),  but  pro- 
ceed much  more  slowly.  In  this  process  the  ferment,  itself,  remains 
unchanged.  Ferment  action  is  specific,  that  is,  each  ferment  manifests 
its  activity  only  on  substances  of  certain  structural  and  stereochemical 
arrangement." 

I  am  conscious  that  my  translation  of  this  definition  is  not  altogether 
satisfactory,  and  in  order  to  give  a  more  exact  interpretation  of  it, 
as  I  understand  it,  I  offer  the  following  explanatory  statements: 

( I )  Every  ferment  is  a  cellular  product ;  it  is  a  cellular  secretion ; 


ACUTE  OBSTRUCTION  OF  THE  BOWEL.  IS 

a  substance  of  definite  chemical  composition  formed  by  the  rearrange- 
ment of  the  atomic  groups  within  the  cellular  molecule. 

(2)  The  action  of  the  ferment,  while  it  is  determined  by  the  cell 
which  produces  it,  is  not  concerned  in  the  "energy  traffic"  constantly 
going  on  between  the  molecules  of  the  cell  which  produced  it  and  other 
molecules  external  to  this  cell.  With  our  present  limited  knowledge 
of  the  chemistry  of  the  cell  molecule  it  is  impossible,  in  many  cases  at 
least,  to  distinguish  between  the  chemical  reactions  resulting  from  cell 
metabolism  and  those  due  to  ferments.  I  am  inclined  to  the  opinion 
that  more  exact  knowledge  will  show  that  the  autolytic  changes  that 
take  place  in  many  cells  after  death,  and  which  have  furnished  the 
theme  of  so  many  papers  recently,  will  be  found  not  to  be  due  to  fer- 
ments at  all,  but  to  the  cessation  of  metabolic  reaction. 

(3)  The  function  of  a  ferment  is  to  hasten  chemical  reactions  which 
take  place,  but  much  more  slowly,  without  the  presence  of  the  ferment. 
It  seems  to  me  that  a  clear  conception  of  this  point  gives  one  a  key  to 
the  action  of  ferments  in  general.  I  have,  in  the  first  part  of  this 
paper,  called  attention  to  the  fact  that  inertia  is  a  universal  property  of 
matter;  that  the  direction  and  rate  of  movement  in  matter  can  not 
be  altered  spontaneously.  A  ferment  is  a  substance  which  by  its 
presence  changes  the  tempo  of  chemical  reaction.  I  am  fully  aware 
that  this  does  not  explain  why  the  ferment  acts  by  its  presence,  but 
it  is  worth  much  to  have  a  conception  of  hozv  it  acts,  provided,  of  course, 
that  this  conception  be  correct.  Furthermore,  it  must  be  admitted  that 
the  modus  operandi  of  ferments  is  still  beyond  our  ken.  Some  think 
that  certain  atoms  or  atomic  groups  are  detached  from  one  of  the  sub- 
stances, combine  with  the  ferment,  and  then  are  passed  on  to  the  other 
substance.  On  this  supposition  the  ferment  does  enter  into  the  reac- 
tion, but  is  constantly  regenerated.  Others  hold  that  the  ferment 
combines  with  the  fermentable  substance,  making  its  molecule  so  labile 
that  it  falls  to  pieces,  and  that  in  the  dissociation  the  ferment  is  again 
set  free.  There  are  weighty  objections  to  either  of  these  theories,  but 
time  will  not  permit  me  to  state  them  in  this  paper,  which  is  intended 
to  be  suggestive  rather  than  exhaustive. 


ON  THE  DIAGNOSIS  OF  ACUTE  OBSTRUCTION  OF 
THE  BOWEL.* 

By  THEODORE  A.  McGRAW.  A.  B.,  M.  D.,  LL.  D..  Detroit,  Michigan. 

I  OP  SVBGBRY  AND  CLINICAL  SURGBRT  IN  THB  OBTROIT  COLLBGB  OF   MBDICINB. 


Disorders,  which  increase  rapidly  in  virulence  and  if  unrelieved 

cause  speedy  death,  demand  early  and  correct  diagnosis  and  positive 

treatment.     Of  such,  there  are  none  which  are  more  urgent  than  acute 

intestinal  obstructions,  and  none  in  which  hesitation  and  delay  are  more 

disastrous.     The  physician  who  ponders  too  long  in  these  cases  over 

the  diagnosis,  comes  to  a  decision  too  late  for  his  patient's  salvation. 

*Read  at  the  Add  Arbor  meetitifB^  of  the   First    Concilor   District   Medical 
Society,  December,  22,  1905. 


14  ORIGINAL  ARTICLES. 

Schlange  divides  intestinal  obstructions  into  two  classes,  the  dynamic 
and  the  mechanical.  The  dynamic  are  paralytic  conditions  which  are 
usually  secondary  to  other  troubles.  They  may  be  caused  by  nervous 
shock.  I  met  with  this  form  once  in  a  case  of  acute  pancreatitis,  which 
I  operated  on  in  Monroe  with  Doctor  Southworth.  A  man  of  forty- 
five  years  was  seized  with  a  violent  pain  in  the  epigastrium  and  fell  at 
once  into  a  collapse.  I  saw  him  twenty-four  hours  later.  He  had  then 
rallied  s(»newhat  but  was  suffering  great  pain  in  the  abdomen.  There 
was  great  distension  and  the  abdomen  was  very  sore.  I  diagnosticated 
the  trouble  as  perforation  by  a  gastric  ulcer  and  expected  to  find  the 
intestines  highly  inflamed.  On  opening  the  abdomen,  however,  I 
found  them  of  normal  color  and  appearance  but  highly  distended  with 
gas.  On  lifting  up  the  stomach  an  abscess  was  discovered  in  the  tail 
of  the  pancreas. 

These  cases  are  uncommon.  The  usual  cause  of  dynamic  obstruc- 
tion is  inflammation  of  the  peritoneum  of  which  the  type  is  a  sup- 
purative appendicitis.  The  treatment  of  these  cases  is  that  proper  for 
the  inflammation  which  causes  them.  Their  symptoms,  pathology  and 
treatment  have  been  the  subject  of  innumerable  treatises  and  discus- 
sions and  are  familiar  to  all  intelligent  practitioners.  I  shall  not,  there- 
fore, discuss  them  in  this  paper  but  confine  my  remarks  to  obstructions 
caused  by  mechanical  forces.  These  include  all  cases  of  hernia,  vol- 
vulus and  intussusception,  and  of  obstructions  caused  by  inflammatory 
bands,  by  adherent  diverticulums,  by  tumors  and  cancers,  by  faults  in 
development  and  by  fecal  impactions  and  foreign  bodies. 

Mechanical  obstructions  may  be  divided  into  two  classes:  those 
which  suddenly  and  completely  occlude  a  gut  and  those  which  cause 
only  a  partial  stenosis  of  slow  development.  This  is  a  highly  practical 
division,  inasmuch  as  the  two  classes  differ  much  in  symptoms  and 
demand  different  treatment. 

It  is  the  obstructions  due  to  the  various  forms  of  strangulation  and 
to  intussusception  which  are  most  speedily  fatal  and  which,  never- 
theless, if  operated  on  early,  offer  the  best  results.  In  many  cases 
an  operation  in  the  first  twelve  hours  after  the  seizure  would  have  little 
more  danger  than  an  exploratory  incision,  while  operations  after  the 
lapse  of  forty-eight  hours  are  almost  always  followed  by  death.  The 
symptoms  caused  by  all  these  various  forms  of  acute  mechanical 
obstruction  are  uniformly  the  same,  modified  only  by  the  seat  of  the 
obstruction,  as  it  occurs  in  the  large  or  small  intestine,  and  by  the 
idiosyncracies  of  the  patient.  There  is  first  a  sudden  and  violent  pain 
in  the  abdomen,  followed  by  nervous  shock  and  vomiting.  There  is 
in  the  first  twelve  hours,  as  a  rule,  but  little  abdominal  tenderness  and 
the  patient  rarely  objects  to  the  manipulation  of  the  abdomen  by  the 
surgeon.  Almost  immediately,  however,  there  begins  a  perceptible 
distension  of  the  abdomen  which,  in  the  very  beginning,  is  localized 
and  confined  to  the  affected  coil  but  soon  involves  the  intestines  above 
it.     In  persons  with  thin  abdominal  walls,  the  coil  which  is  the  seat 


ACUTE  OBSTRUCTION  OF  THE  BOWEL.  15 

of  the  injury  may  be  discovered  as  a  projecting  spot  on  the  abdomen. 
It  is  distended  and  paralyzed  and  will  not  contract  under  any  stimulus. 
Vomiting  does  not  relieve  the  nausea,  and  continues  without  cessation. 
The  bowels  are  obsttnately  constipated  and  do  not  respond  to  pur- 
gatives but  may  discharge  such  of  their  contents  as  are  contained  in 
the  part  below  the  constriction.  When,  as  sometimes  happens,  the 
affected  coil  is  in  the  pelvis,  there  may  be  no  distension  of  the  abdomen 
but  the  swollen  intestine  may  be  felt  by  rectal  or  vaginal  examination. 
This  was  the  case  in  a  boy  upon  whom  I  operated  on  the  seventh  of  this 
month.  He  had  been  ill  over  three  days  when  he  was  brought  to  the 
hospital  enormously  distended.  His  physician  told  me  that  the  abdo- 
men during  the  first  two  days  was  flat  and  unsensative.  I  found  a 
black  and  gangrenous  volvulus  of  large  size,  which  I  fished  out  of  the 
pelvis.  In  these  cases  a  careful  examination  of  the  pelvic  cavity 
through  the  vagina  or  rectum  should  never  be  omitted. 

The  course  of  the  distension  in  obstruction  has  an  important  bearing 
on  the  diagnosis.  The  abdomen  is  not  suddenly  inflated  as  in  severe 
acute  enteritis  or  peritonitis ;  aflFecting  at  first  only  one  coil,  the  swelling 
is  for  some  hours  localized  and  moderate,  and  only  gradually  extends 
to  the  gut  which  lies  above  the  constriction.  In  the  last  stages,  how- 
ever, the  whole  abdomen  may  become  swollen  to  its  utmost  capacity. 
In  fat  people  it  is  much  more  difficult  to  map  out  the  affected  coils. 

It  is  characteristic  of  obstruction  in  the  early  stages  that  the  result- 
ing swelling  is  comparatively  free  from  soreness.  I  have,  indeed,  seen 
several  patients  in  whom  this  freedom  from  tenderness  on  pressure 
continued  into  the  second  and  third  day,  even  though  they  were  suffer-  * 
ing  extreme  pain.  In  fact,  I  have  come  to  look  upon  the  disproportion 
between  the  pain  of  obstruction  and  the  soreness  of  the  abdomen  as 
pathognomonic  of  the  disorder.  A  patient  will  from  the  very  begin- 
ning complain  bitterly  of  pain  but  will,  without  flinching,  allow  the 
surgeon  to  thoroughly  manipulate  and  examine  the  abdomen.  There 
may  be  some  tenderness  in  spots  but  it  is  comparatively  slight  and 
unimportant.  There  are  very  few  morbid  conditions  in  which  this 
contrast  between  agonizing  abdominal  pain  and  nearly  complete  free- 
dom from  abdominal  soreness  are  found  in  the  same  degree.  Cor- 
responding with  this  freedom  from  soreness,  the  abdominal  walls,  in 
most  cases,  are  relaxed  and  devoid  of  tension  until,  at  the  end  of  thirty- 
six  or  forty-eight  hours,  all  symptoms  become  aggravated  by  septic 
absorption.  The  increase  of  indican  in  the  urine  is  of  no  avail  for 
early  diagnosis,  as  it  does  not  become  apparent  before  the  lapse  of 
twenty-four  hours.  In  obstruction  the  temperature  remains  nearly 
normal  until  the  conditions  become  septic,  when  it  will  rise  rapidly 
and  continuously  until  death.  It  is  on  the  combination  of  symptcwns 
and  on  the  order  of  the  sequence  that  the  physician  must  base  his 
diagnosis.  There  is  not  a  S3rmptom  of  obstruction  which  may  not  be 
present  in  other  maladies  but  there  are  few  diseases  in  which  they  will 
occur  in  the  same  order  and  in  the  same  connection. 


le  ORIGINAL  ARTICLES. 

If  we  pass  in  review  the  other  troubles  which  may  perplex  the  prac- 
titioner in  his  diagnosis  we  may  gain  a  clearer  picture  of  that  first  stage 
in  which  alone  operations  can  be  done  with  nearly  certain  success. 

Obstruction  may,  first  of  all,  be  mistaken  for  indigestion  with 
autointoxication.  The  severer  forms  of  this  kind  of  trouble  are 
sometimes  ushered  in  by  severe  abdominal  pain,  vomiting  and  collapse, 
followed  by  some  tenderness  and  distension.  It  is  rarely,  however, 
that  the  nervous  shock  is  as  severe  as  in  obstruction.  The  pain  is 
more  colicky  in  character,  the  bloating,  when  it  occurs,  is  less  localized 
and  of  more  rapid  development,  and  there  is  more  fever.  The  one 
deciding  symptom  is  the  occurrence  of  diarrhea,  which  is  the  usual 
result  of  the  condition.  Should  the  bowels  not  move  spontaneously, 
purgatives  or  enemas  will  almost  invariably  produce  the  desired  effect. 
This  is  the  rule,  too,  with  all  forms  of  enteritis.  Osier,  indeed,  men- 
tions a  case  which  was  mistaken  for  obstruction  but  does  not  say  any- 
thing as  to  the  condition  of  the  bowels.  The  coexistence  of  constipa- 
tion with  severe  enteritis  is  so  rare  that  it  may  be  left  out  of  our 
calculations  in  forming  our  opinion. 

Bilious  colic  produced  by  the  passage  of  gall-stones  may  cause 
great  agony,  feeble  pulse,  vomiting  and  temporary  collapse.  It  is» 
however,  usually  of  short  duration  and  causes  neither  bloating  nor  con- 
stipation. If  the  trouble  is  prolonged,  there  will  be  tenderness  in 
the  region  of  the  gall-ducts,  and  if  the  common  duct  is  the  seat  of  the 
disorder,  there  will  be  jaundice.  It  rarely  causes  the  permanent  pros- 
tration of  obstruction,  unless  associated  with  severe  suppurative 
cholecystitis,  in  which  case  there  will  be  chills  and  high  fever  as  well 
as  great  local  soreness. 

The  colic  of  lead  poisoning  could  hardly  be  mistaken  for  intestinal 
obstruction,  notwithstanding  the  occurrence  of  constipation.  The  his- 
tory of  the  patient,  his  occupation,  his  continued  ill  health,  the  blue 
line  of  the  gums  are  all  distinguishing  features.  The  symptoms  are 
relieved  by  opium  and  the  constipation  is  apt  to  alternate  with  diarrhea. 
The  patient  has  a  history  of  multiple  attacks,  which  gradually  increase 
in  severity.  There  is  not  much  distension  and,  if  any  exists,  it  will 
disappear  under  opiates,  in  this  respect  differing  sharply  from  the  dis- 
tension of  obstruction. 

In  renal  colic  the  patient  often  suffers  severe  shock  and  great  pain. 
There  is  sometimes,  but  not  always,  nausea  and  vomiting.  The  pain 
aflfects  the  back,  the  kidneys,  the  ureters  and  the  bladder.  Micturition 
is  often  painful  and  the  urine  contains  albumin  and  blood.  There  is 
tenderness  along  the  course  of  the  affected  ureter.  The  bowels  may 
or  may  not  be  constipated,  but  are  rarely  bloated. 

Acute  pancreatitis,  more  than  any  other  malady,  may  simulate  intes- 
tinal obstruction.  Beginning  with  an  agonizing  pain  in  the  abdomen, 
with  great  shock  and  vomiting,  there  is  a  rapid  distension  of  the 
abdomen  and  a  tendency  to  collapse.  The  very  rapidity  with  which 
the  symptoms  develop  distinguishes  the  disorder  from  obstruction,  in 


ACUTE  OBSTRUCTION  OF  THE  BOWEL.  17 

which  the  growth  of  the  abdominal  distension  is  much  more  slow. 
•The  pain  in  pancreatitis  and  the  tenderness  are  felt  across  the  abdo- 
men in  the  region  of  the  pancreas.  The  fever  of  pancreatitis  begins 
much  earlier  than  that  of  intestinal  stoppage.  As  regards  those  inflam- 
matory affections  which  cause  bloating  and  intestinal  paralysis,  they  are 
all  distinguished  by  high  fever,  leucocytosis  and  abd<nninal  tension  and 
need  no  further  discussion  in  this  place.  In  the  diagnosis  of  invagina- 
tion, the  finger  may  often  detect  the  invaginated  gut  in  the  rectum  in 
the  shape  of  the  end  of  a  tube  projecting  into  the  bowel.  This  feeling, 
however,  may  be  very  deceptive,  as  I  found  in  a  case  of  Doctor  Qiapo- 
ton's  upon  which  I  operated.  The  child  had  a  severe  attack  of  obstruc- 
tion and  I  felt  as  high  up  as  I  could  reach  a  protrusion  of  this  form. 
On  abdominal  section,  however,  I  found  no  invagination  but  a  volvulus 
high  up.  The  pelvis  was  full  of  distended  coils  of  intestines,  whose 
pressure  upon  the  rectal  wall  had  forced  it  in  and  caused  the  deceptive 
protusion. 

In  discussing  the  symptoms  of  acute  obstruction  we  must  not  forget 
those  forms  caused  by  the  obturation  of  the  gut  by  intestinal  contents. 
I  was  once  called  into  the  country  to  operate  on  a  woman  who  had  the 
evening  before  eaten  an  enormous  quantity  of  pop  corn,  which  she  did 
not  even  take  the  trouble  to  chew.  I  found  her  suffering  from  agon- 
izing pain  which  had  continued  for  the  twenty-four  hours.  Her 
abdomen  was  enormously  distended.  I  was  preparing  to  operate, 
when  she  had  a  sudden  evacuation  of  a  g^eat  mass  of  undigested  pop 
com,  and  relief  from  all  her  symptoms.  It  is,  of  course,  important  to 
distinguish  these  cases  from  those  in  which  the  stoppage  is  due  to 
strangulation  or  intussusception. 

I  have  not  spoken  of  the  later  symptoms  of  obstruction,  such  a  fecal 
vomiting,  high  fever,  and  failing  pulse,  because  the  diagnosis  should 
never  wait  upon  their  appearance.  I  am  confident  that  in  nineteen 
cases  out  of  twenty  the  physician  could  diagnosticate  acute  obstruction, 
if  he  would  become  thoroughly  conversant  with  the  typical  symptoms. 

If  a  patient  is  seized  with  an  agonizing  pain  in  the  abdomen,  fol- 
lowed by  shock,  nausea,  vomiting  and  collapse, — if  then  there  occurs  a 
localized  swelling  of  the  abdomen  or  pelvic  cavity,  if  in  that  swelling 
no  stimulus  can  cause  vernricular  motion,  if  during  the  twenty-four 
hours  there  is  very  little  abdominal  tenderness  and  no  abdominal  ten- 
sion, if  the  bowels  are  obstinately  constipated,  if  the  abdominal  swelling 
slowly  increases  until  the  afferent  coils  all  become  distended,  if  with  all 
of  the  disturbance  there  is  little  or  no  rise  in  temperature,  there  can  be 
no  doubt  as  to  the  nature  of  the  trouble,  for  there  is  no  other  malady 
which  will  offer  the  same  complex  of  symptoms  in  the  same  sequence. 

Those  cases  only  are  doubtful  in  which  some  of  these  symptoms  are 
lacking  or  are  modified  by  the  existence  of  other  morbid  conditions. 
Thus  the  localization  of  the  primary  swelling  may  be  rendered  impos- 
sible by  a  fat  abdomen.  There  may  be  some  chronic  inflammatory  con- 
dition caiising  abdominal  tenderness,  tension  and  swelling.    There  may 


18  ORIGINAL  ARTICLES. 

be  one  or  two  evacuations  of  feces  which  have  been  lodged  below  the 
point  of  obstruction,  and  there  may  be  histories  of  previous  attacks  of 
abdominal  pain  which  may  prejudice  the  diagnosis,  but  even  with  all 
the  possibilities  of  mistake,  a  careful  watch  and  intelligent  analysis  of 
the  phenomena  will  usually  lead  to  a  correct  conclusion. 

Even  when  the  diagnosis  of  obstruction  has  been  made,  the  occur- 
rence of  a  fecal  evacuation  and  the  subsidence  of  some  of  the  more  dis- 
tressing symptoms  may  lead  to  a  mistaken  belief  that  there  has  been  a 
correction  of  the  morbid  condition.  The  patient  may  feel  relief  from 
pain,  but  the  distension  increases,  the  pulse  beats  faster  and  feebler  and 
the  temperature  rises.  It  may  be  laid  down  as  a  positive  rule  that 
relief  from  obstruction  is  always  followed  quickly  by  a  relief  from 
distension. 

This  is  an  index  to  which  the  physician  should  look  for  guidance 
when  there  is  an  apparent  improvement,  and  never  delay  operative 
measures  when  the  distensk>n  is  persistent.  We  may  hope  to  cure 
cases  of  complete  acute  obstruction  only  when  we  meet  the  emergency 
by  operation  within  the  first  twenty-four  hours,  and  it  behooves  every 
practitioner  of  medicine  to  study  carefully  the  means  of  diagnosis  and 
to  be  prompt  in  his  action. 


TRANSACTIONS. 


CLINICAL  SOCIETY  OF  THE  NEW  YORK  POLYCLINIC. 


STATED  MEETING,  DECEMBER  4,  1905. 
The  President,  JOHN  J.  MacPHEE,  M.  D.,  in  the  Chair. 
Reported  by  FREDERICK  C.  KELLER,  M.  D.,  Secretary. 

READING  OF  PAPERS. 
SURGICAL  HERESY. 

Doctor  John  A.  Bodine  read  a  paper  bearing  the  above  title.  He 
said  in  part : 

The  first  slipping  away  from  the  faith  of  our  forefathers  was  in 
"Where  and  How  to  Amputate."  No  article  in  textual  creed  is 
stronger  than,  "Save  all  you  can  in  amputations."  The  various  and 
multiform  amputations  through  the  complex  tarsus  and  metatarsus 
bones  were  the  result  of  the  necessity  for  speed  before  the  advent  of 
anesthesia.  This  golden  rule  was  also  strengthened  by  the  argument 
that  in  amputations  the  nearer  the  trunk  the  greater  the  death  rate,  Ad 
still  further  bedrocked  in  the  belief  of  the  patient  that  the  less  of  his 
anatomy  lost,  the  less  xA  a  cripple  he  was.  The  advent  of  skilled  pros- 
thetic surgery  has  done  away  with  peg-legs  and  crutches  for  the  unfor- 
tunate victims  of  amputations,  and  today  instead  of  traditional  anatomic 
and  sentimental  arguments,  one  should  be  guided  by  a  new  article  of 


CLINICAL  SOCIETY.  1» . 

faith :  "Amputate  where  the  limbmaker  can  best  supply  the  loss."  Save 
all  you  can  from  tip  of  toe  to  the  tarso-metatarsal  joint,  and  discard 
every  one  of  the  many  technical  amputations  through  the  tarsus  in 
favor  of  the  Syms'  amputation  at  the  ankle-joint.  There  is  weighty 
prosthetic  evidence  that  even  this  point  of  amputation  should  be  dis- 
carded in  favor  of  removal  seven  inches  above  the  ground  line.  There 
is  but  one  American  firm  of  limbmakers  which  claims  it  can  fit  partial 
foot  amputations  with  a  satisfactory  appliance,  and  even  it  admits  that 
the  advantage  is  chiefly  economic,  the  apparatus  costing  less  than  in 
the  case  of  higher  amputations. 

After  leaving  the  point  of  seven  inches  above  the  ground  line,  the 
rule  of  save  every  inch  possible  holds  good  until  within  two  inches  of 
the  knee-joint.  In  amputations  of  the  thigh  above  this  point,  one 
should  save  every  inch  possible. 

In  the  event  of  future  improvements  in  artificial  substitutes,  nulli- 
fying the  potency  of  the  speaker's. argument,  he  submitted  that  in  par- 
tial foot  amputations  the  technical  and  ccxnplicated  textual  amputations 
should  be  ^discarded  and  the  foot  treated  as  one  bone,  the  rule  then 
being,  "Save  all  you  can,  from  toe  to  hip-joint." 

There  is  a  tendency  today  Jo  attach  too  much  importance  to  the 
laboratory  verdict  in  diagnosis  of  surgical  lesions.  Important  as  this 
evidence  is,  it  is  not  always  pathognomonic,  and  in  few  surgical  diseases, 
alone  and  unaided,  can  it  be  relied  upon  to  formulate  a  diagnosis.  It 
furnished  evidence,  valuable  evidence,  but  unless  clihical  history  and 
clinical  symptoms  support  this  testimony  the  laboratory  evidence  should 
be  discarded.  In  the  surgical  lesions  of  the  stomach,  can  cancer, 
pyloric  obstruction  or  ulcer  be  diagnosticated  alone  by  the  test-tube  or 
microscope?  Can  chemical  or  microscopic  examination  of  the  feces 
locate  or  even  diagnosticate  surgical  lesions  of  the  intestinal  tract? 
Which  should  one  refuse  elective  operation,  a  patient  who  passed  a 
low  quantity  of  urine,  with  low  specific  gravity,  or  one  with  full  quan- 
tity of  normal  specific  gravity,  with  all  the  pathologic  casts  and  epithe- 
lium discoverable  with  the  microscope  ? 

DISCUSSION. 

Doctor  Ferdinand  M.  Jeffries:  So  far  as  Doctor  Bodine's 
remarks  concern  the  laboratory,  I  must  agree  with  him  in  the  main, 
but  some  of  his  assertions  I  cannot  coincide  with.  With  regard  to 
cancer,  I  feel  that  if  the  pathologist's  report  is  that  of  cancer,  no 
matter  what  the  clinical  findings  may  be  the  surgeon  should  proceed 
on  the  assumption  that  it  is  malignant  in  character.  Regarding  appen- 
dicitis, it  is  generally  known  that  hematology  is  not  the  useful  diag- 
nostic aid  that  at  one  time  it  was  hoped  it  would  be,  nevertheless, 
instances  are  on  record  in  which  it  has  been  of  great  service.  There- 
fore, the  patient  should  be  given  the  benefit  of  this  examination  on  all 
occasions.  The  surgeon  should  give  the  benefit  of  all  clinical  aids ;  the 
laboratory  is  one  of  them. 


20  ORIGINAL  ARTICLES. 

REPORTS  OF  CASES. 
ATRESIA  OF  THE  BOWEL, 

Doctor  Joseph  E.  Fuld:  I  wish  to  show  this  specimen.  The 
child  was  bom  normally,  at  full  term,  and  on  the  morning  of  the  third 
day  vomited  material  which  looked  like  meconium.  It  had  not  defe- 
cated since  birth,  and  refused  the  breast.  ^Physical  examination  showed 
a  well-formed,  healthy  baby,  with  no  outward  deformities.  The  abdo- 
men presented  marked  lateral  and  median  distension,  but  no  signs  of 
hernia.  Examination  with  a  large  sized  Kelly  cystoscope  showed  a 
distinct  narrowing  of  the  lumen  of  the  bowel  between  one  and  one- 
half  and  one  and  three-quarters  inches  from  the  anus.  In  the  centre  of 
the  narrowest  part  a  small  dimple  was  distinctly  visible,  and  through 
this  a  uterine  sound  was  introduced  with  some  difficulty  for  about  one 
and  one-quarter  inches.  No  mass  could  be  felt  in  the  pelvis.  A  diag- 
nosis of  atresia  recti  was  made,  and  iliostomy  was  performed  under 
chloroform  anesthesia.  A  median  incision  two  inches  long  was  made 
below  the  umbilicus,  and  in  trying  to  get  into  the  peritoneal  cavity  the 
much-distended  bladder,  which  resembled  the  parietal  peritoneum,  was 
nicked  and  considerable  urine  escaped.  An  artificial  anus  was  made 
in  the  lowest  part  of  the  ileum,  which  was  packed  off  and  surrounded 
with  gauze.  The  patient  left  the  table  in  a  fair  condition,  but  was  not 
rielieved  by  the  operation,  and  died  thirteen  hours  later.  Postmortem 
examination  showed  the  small  intestine  to  be  full  of  meconium  and 
considerably  distended.  The  pylorus  was  distinctly  thickened  for  a 
distance  of  about  three-quarters  of  an  inch,  making  a  firm  ring,  and 
producing  a  slight  stenosis.  Section  through  the  thickened  tissue 
showed  very  marked  increase  of  the  muscular  layer.  At  the  normal 
end  of  the  ileum,  instead  of  the  normal  valve  there  was  complete 
closure.  Beyond  this  the  large  bowel  was  patent  throughout,  com- 
municating below  with  the  rectum.  In  the  centre  of  the  septum  was  a 
dimple,  corresponding  to  the  ileocecal  valve.  The  large  bowel  wa:> 
the  size  of  an  adult  ureter,  and  the  cecum  was  about  three-quarters  of 
an  inch  in  length  and  about  twice  the  size  of  the  sigmoid  colon. 

SPONTANEOUS  RUPTURE  OF  THE  UTERUS  DURING  PREGNANCY, 

Doctor  Louis  J.  Ladinski  :  I  desire  to  show  a  uterus  and  adnexa 
which  I  removed  from  a  patient  about  a  week  ago.  The  history  given 
was  that  pregnancy  followed  four  years  after  operation  at  the  Polyclinic 
Hospital,  and  just  prior  to  impregnation  there  was  chronic  endome- 
tritis with  mattery  discharge.  Examination  through  the  vagina  during 
the  fourth  month  of  pregnancy  showed  the  uterus  to  be  adherent,  but 
there  was  no  deformity  in  size,  form  or  position.  Three  days  before 
operation  a  small  blood  spot  was  noticed,  and  I  adyised  absolute  rest 
in  bed  and  morphin.  There  was  no  further  showing  of  blood,  but  the 
following  day  the  patient  complained  of  pain  in  her  back,  and  two  days 
later  she  collapsed.  Her  pulse  was  rapid  and  almost  imperceptible  at 
times,  and  she  had  intense  pallor  and  rapid  respiration.     Her  abdomen 


CLINICAL  SOCIETY.  21; 

was  distended,  not  in  the  shape  of  a  dome,  but  over  its  entire  surface. 
A  diagnosis  of  ruptured  abdominal  pregnancy  was  made,  and  immedi- 
ate operation  advised.  When  the  patient  was  placed  on  the  operating 
table  the  fetus  was  found  in  its  sac,  floating  about  in  the  abdomen. 
There  was  a  large  rent  in  the  uterus.  The  patient  made  a  good 
recovery.  Uterine  rupture  during  pregnancy  is  rare,  and  must  not  be 
confounded  with  rupture  during  labor.  The  most  frequent  cause  for 
the  former  is  the  giving  way  of  the  scar  of  a  previous  Cesarean  section, 
or  of  the  connective  tissue  formed  after  a  deep  curettage.  In  the  case 
described,  one  portion  of  the  posterior  wall  of  the  uterus  was  as  thin  as 
paper.  If  a  history  of  the  operation  performed  four  years  before  could 
be  obtained  it  would  assist  in  determining  the  cause  of  this  condition. 

DISCUSSION. 

Doctor  Benjamin  Torrens  :  Possibly  the  patient  was  the  same  as 
one  on  whom  I  operated  about  four  years  ago  at  the  Polyclinic  Hos- 
pital. On  inserting  the  curet  into  the  uterine  cavity,  it  was  found  that 
the  instrument  entered  the  abdominal  cavity  through  an  opening  in  the 
anterior  uterine  wall.  It  was  immediatly  withdrawn,  and  digital 
examination  disclosed  two  perforations  of  the  wall,  with  about  one  inch 
of  connective  tissue  separating  them.  Each  of  the  openings  was  large 
enough  to  admit  the  passage  of  two  fingers.  The  uterus  was  packed 
with  iodoform  gauze,  the  culdesac  of  Douglas  was  opened,  and  the 
small  intestine  was  found  adherent  to  the  anterior  uterine  wall  at  the 
site  of  perforation.  This  was  detached  and  the  pelvis  packed  with 
gauze.    The  patient  made  an  uneventful  recovery. 

Doctor  Robert  H.  M.  Dawbarn:  This  case  reminds  me  of  an 
instance  in  which  I  made  a  diagnosis  of  abdominal  rupture  of  preg- 
nancy, even  going  so  far  as  to  determine  the  position  of  the  fetus. 
There  was  some  bleeding  from  the  uterus,  which  was  enlarged  and 
quite  soft.  The  abdomen,  when  opened,  allowed  the  escape  of  a  very 
great  amount  of  bloody  material,  and  this  being  removed,  it  was  seen 
that  all  of  the  viscera,  the  bowels  especially,  were  covered  with  a  new 
growth  which  proved  to  be  sarcoma,  the  largest  clump  of  which  had 
been  mistaken  for  the  fetus. 

DERMOID  CYST. 

Doctor  Dawbarn  :  I  also  wish  to  show  a  dermoid  cyst  which  I 
removed  a  week  ago  from  a  girl  nine  years  of  age.  The  dermoid  is 
much  larger  than  the  average  specimen  of  its  kind.  There  is  a  Kstory 
of  half  a  dozen  paroxysms  of  pain,  and  when  the  specimen  was  removed 
the  pedicle  was  found  to  be  twisted  upon  itself  a  great  many  times. 
Apparently  this  occurred  coincidentally  with  the  pain,  and  of  course 
occasioned  hemorrhage  of  the  sac.  The  solid  portion  of  the  cyst  is 
about  the  size  of  a  small  tgg  and  is  filled  with  teeth  and  bones. 

TENDON  TRANSPLANTATION  IN  THE  FOREARM, 

Doctor  John  A.  Bodine  :  I  wish  to  present  this  patient.  He  is  a 
butcher  by  trade,  and  was  on  the  top  of  a  high  stepladder  when  he 
slipped  and  caught  at  a  large  meat  hook  on  the  side  of  the  wall.    The 


22  ORIGINAL  ARTICLES. 

hook  penetrated  the  forearm  at  the  base  of  the  thum,  picking  up  the 
three  tendons  on  the  radial  side — the  two  tendons  forming  the  anatom- 
ical snuff-box  and  that  of  the  supinator  longus.  He  swung  from  this 
hook  with  his  entire  weight  of  one  hundred  seventy  pounds.  The 
tendons  did  not  break,  but  pulled  loose  from  their  attachments  to  the 
muscles  in  the  forearm,  one  of  them  hanging  down  for  twelve  inches. 
He  wrapped  his  butcher  apron  around  the  forearm  and  tendons  and  in 
a  few  hours  was  on  the  operating  table.  The  tendons  were  identified 
and  two  of  them  passed  through  the  canal  in  the  anterior  ligament  of 
the  wrist  and  sutured  in  their  proper  positions.  The  loose  tendon  of 
the  supinator  longus,  however,  was  so  long  that  opening  of  the  muscu- 
lar planes  of  the  forearm,  near  the  elbow,  would  have  been  necessary  in 
order  to  stitch  it  in  place.  It  was  therefore  thought  best  to  transplant 
it  into  the  tendons  of  the  extensor  primi  internodii  pollicis.  The  wound 
healed  kindly  and  the  patient  can  now  do  with  this  thumb  all  that  he 
can  do  with  the  other  one. 

VARICOSE  VEINS  OF  THE  LOWER  L2MB, 

Doctor  Bodine:  I  also  wish  to  present  this  patient.  Of  middle 
life,  she  presented  for  operation  the  worst  type  of  this  condition.  Great 
masses  of  infected  thrombi  were  present  on  the  inner  side  of  the  leg. 
Three  weeks'  rest  in  bed,  with  ice-bags,  et  cetera,  was  insisted  upon, 
until  all  inflammation  and  sepsis  had  disappeared.  She  was  then  oper- 
ated upon.  It  is  my  belief  that  when  the  Trendelenberg  operation  can- 
not be  utilized  the  only  other  to  be  recommended  is  that  of  excision  of 
the  entire  internal  saphenous  vein,  because  if  the  blood  current  in  the 
vein  is  cut  off  by  any  other  operation,  the  walls  of  the  useless  vein  may 
become  a  foreign  body  and  require  removal.  The  operation  recom- 
mended by  me  is  that  of  Caseta,  in  which  the  entire  vein  is  removed 
through  three  or  four  small  cuts  in  the  overlying  skin,  the  vein  being 
pulled  out  subcutaneously,  the  numerous  tributary  vessels  being  torn 
across,  but  not  litigated.  At  the  junction  of  the  middle  with  the  lower 
third  of  the  leg,  the  skin  and  subcutaneous  fascia  are  then  cut  through 
to  the  muscles,  the  cut  encircling  the  entire  limb.  After  this  operation 
the  patient  is  usually  in  the  hospital  for  two  weeks.  In  every  one  of 
the  twenty  cases  in  which  the  speaker  had  operated  according  to  this 
method  the  cure  had  been  perfect. 

ACUTE  INFECTIOUS  CHOLECYSTITIS. 
Doctor  Bodine:  Here  is  a  girl,  seven  years  of  age,  who  entered 
the  hospital  fot^r  weeks  ago.  The  question  of  diagnosis  is  interesting 
in -this  case,  because,  judging  from  the  symptoms,  the  condition  might 
have  been  intestinal  obstruction,  pneumonia,  diaphragmatic  abscess, 
appendicitis,  or  acute  infectious  cholecystitis.  As  is  well  known,  at 
times  it  is  very  difficult  to  differentiate  in  these  acute  abdominal  lesions. 
Her  vomiting  was  not  progressive  and  her  fever  was  too  high  for 
intestinal  obstruction.  The  principal  point  of  tenderness  was  too  high 
>  for  appendicitis,  unless  it  were  of  the  type  in  which  the  pain  is  reflected 
to  the  liver.     Her  entire  right  abdomen  was  rigid,  and   respiration. 


HEART  DISEASE  OF  NEPHRITIS  28 

while  rapid,  was  not  the  dominant  feature  of  the  situation,  although  a 
cough  was  present  from  bronchitis.  Diagnosis  of  acute  infection  of 
the  gall-bladder  was  therefore  tentatively  made,  and  proved  correct  on 
operation.  The  liver  was  two  and  one-half  inches  below  the  costal 
border,  and  projecting  below  the  liver  was  the  tense,  swollen  gall- 
bladder. This  was  quickly  stitched  to  the  abdominal  wall,  drained, 
but  not  removed.  The  child's  condition  was  so  critical  that  speed  was 
an  essential  feature  of  the  case.  Four  months  previous  to  this  illness 
she  had  an  unusually  severe  attack  of  measles,  followed  by  a  persistent 
bronchitis  and  cough.  From  .that  time  to  the  present  illness  she  has 
complained  frequently  of  pain  in  the  pit  of  her  stomach,  so  it  seems 
quite  probable  that  the  measles  were  the  cause  of  the  infected  gall-blad- 
der by  metastasis. 

ORIGINAL  ABSTRACTS. 


MEDICINE. 

By  GEORGE  DOCK,  A.M.,  M.  D.,  D.Sc,  Ann  Arbor,  Michigan. 

PltOFUSOR  OF  MBDICINS  IN  TMB  UMIVBRSITY  OP  BflCMIGAlt. 

AND 

DAVID  MURRAY  COWIE,  M.  D.,  Ann  Arbor,  Michigan. 

FIRST  ASSISTANT  IN  BfBDIClNB  IN  THB  UNIVBBSITV  OF  BflCMIGAN. 


THE  CAUSE  AND  IMPORTANCE  OF  THE  HEART  DIS- 
EASE OF  NEPHRITIS. 

Passler  (Sammlung  Klin.  Vortrdge,  Inn.  Med.  Number  CXXIII) 
has  made  a  study  of  this  subject,  so  often  discussed  in  the  past,  and  has 
brought  to  it  the  most  advanced  knowledge  of  cardiac  physiology  and 
pathology,  since  he  has  been  an  active  coworker  with  Krehl,  Romberg 
and  others  of  the  Leipzig  school.  Only  the  most  important  conclusions 
can  be  given  here. 

( 1 )  The  cardiac  hypertrophy  in  nephritis  is  the  result  of  the  kidney 
disease. 

(2)  There  is  probably  at  first  an  increased  irritability  of  the  vaso- 
'constrictor  apparatus  in  consequence  of  the  renal  lesion,  subsequently 

arterial  spasm  and  increased  resistance  of  the  greater  circulation.  In 
cases  where  there  is  extensive  arteriosclerosis,  especially  in  the  thoracic 
aorta  or  the  small  arteries  of  numerous  organs  in  the  splanchnic  area, 
part  of  the  hypertrophy  of  the  left  ventricle  must  be  attributed  to  this 
complication. 

(3)  The  hypertrophy  of  the  left  auricle  and  the  right  heart  in 
nephritis  is  a  result  of  insufficiency  of  the  left  ventricle. 

(4)  The  polyuria  of  many  renal  diseases,  especially  of  contracted 
kidney,  does  not  depend  upon  an  increased  "filter  pressure"  of  the 
glomerular  capillaries ;  it  is  much  more  probable  that  the  blood  pressure 


24  ORIGINAL  ABSTRACTS. 

in  the  renal  capillaries  is  not  elevated  above  normal  even  in  cases  of  the 
highest  arterial  pressure,  as  the  excess  must  be  used  in  overcoming  the 
resistance  in  the  small  arteries. 

(S)  Therapeutic  measures  for  preservation  of  compensation,  and 
in  disturbed  compensation  of  the  heart  in  interstitial  nephritis,  must 
regard  not  only  the  increase  of  cardiac  power,  but  more  especially  the 
lowering  of  arterial  r^istance.  (For  the  latter  purpose  the  author 
recommends  nitr(^lyccrin).  G.  d. 


SURGERY. 

By  frank  BANGHART  WALKER,  Ph.  B.,  M,  D.,  Detroit.  Michigan. 

rROVBSSOK  or  SUKGBKT  AMD  OPBRATiyB  SUKGBKT  IN  THB  DBTKOIT  POSTGKADUATB  SCHOOL  OV  MBDICIM 
ADJUMCT  PKOFBStOR  OF  OPBKATIVB  SUBGBKT  IN  THB  DBTBOIT  COLLACB  OF  MBDICINB. 

AND 

CYRENUS  GARRITT  DARLING,  M.  D.,  Ann  Arbor.  Michigan. 

CLINICAL  ntOFBSSOB  OF  SUBGBKT  IN  THB  VNIVBBSITT  OF  MICHIGAN. 


TUBERCULOSIS  OF  THE  CERVICAL  LYMPH  NODES. 

Daniel  Eisendrath,  M.  D.,  of  Chicago,  in  Surgery,  Gynecology 
and  Obstetrics,  Volume  II,  Number  I. 

This  old,  familiar  subject  has  made  some  advances  of  late,  so  that 
the  cause,  diagnosis  and  treatment  at  the  present  time  will  be  consid- 
ered. It  has  long  been  known  that  the  tonsils  are  the  common  portals 
of  entry  of  infection  in  the  cervical  lymph  nodes.  This  has  been  con- 
firmed beyond  doubt  by  examination  of  the  tonsils  and  adenoids 
removed  from  children.  When  the  children  crawl  on  the  floor  their 
tonsils  probably  become  infected  by  the  dust  which  lodges  in  them. 

Infection  may  also  come  from  the  temporal  bone  or  through 
carious  teeth,  by  tubucular  lesions  of  the  buccal  and  mucous  membranes. 
These  latter  represent  a  very  small  proportion  of  the  cases.  The  tuber- 
cular organisms  may  remain  latent  in  the  cervical  lymph  nodes  for  many 
years,  and  then  suddenly  become  active.  Every  case  should  be  care- 
fully examined  before  operation  to  see  if  it  is  complicated  by  disease 
of  the  tonsils,  or  by  the  presence  of  adenoids.  The  diagnosis  of  the 
chronic  forms,  such  as  have  extended  over  .a  period  of  months  or  years, 
will  be  easy,  and  other  cases,  also,  where  the  disease  runs  a  very  acute 
course  so  that  caseation  may  occur,  within  two  or  three  weeks  after  the 
onset  of  the  disease. 

Another  class  should  be  considered  which  Fischer  has  termed  a 
pseudoleukemic  form  of  tubercular  lymph  nodes,  where  the  axillary 
and  inguinal  node  are  enlarged  as  well  as  the  cervical.  There  is  a  grad- 
ual enlargement;  with  no  tendency  to  softening,  or  the  formation  of 
adhesions  between  adjacent  nodes. 

Without  a  reliable  history  it  is  impossible  to  make  a  diagnosis. 
Besides  these  may  be  mentioned  syphilitic  lymphatic  leukemia,  chronic 
nontubercular  hyperplastic  nodes,  lymposarcoma,  and  secondary  car- 


CANCER  OF  THE  UTERUS.  25 

cinomata.  The  treatment  is  divided  into  prophylactic,  nonoperativc, 
and  operative.  Prophylaxis  is  the  same  as  may  be  applied  in  all 
instances  for  avoiding  tuberculosis.  To  this  may  be  added  the  removal 
of  diseased  tonsils  and  adenoids  whenever  found. 

When,  for  any  reason,  an  operation  is  deemed  inadvisable  or  objected 
to,  the  patient  should  be  sent  to  the  mountains  or  seashore.  When  this 
is  impossible  tonics  of  cod-liver  oil,  guaiacol,  or  iodide  of  iron  will  be 
beneficial.    If  the  condition  is  active  medical  treatment  is  of  little  avail. 

The  operative  treatment  consists  in  removing  every  tuberculous 
node,  and,  at  the  same  time,  the  tonsil  and  diseased  adenoids.  The 
incision  is  made  over  the  middle  of  the  sterno-cleido-mastoid  from  one 
end  to  the  other  if  necessary,  and  all  the  sinuses  if  they  exist,  are  dis- 
sected out.  The  muscle  is  pulled  backwards  and  the  nodes  exposed. 
Care  is  taken  to  catch  every  bleeding  point  at  once.  Few  of  the  vessels 
require  ligature  except  the  external  jugular  vein,  which  is  nearly  always 
severed.  The  dissection  is  made  with  blunt-pointed,  short-bladed, 
curved  scissors.  The  writer  states  that  in  this  way  he  has  exposed  the 
internal  jugular  vein  from  the  chin  to  the  clavicle  without  injury.  By 
this  method  nodes  can  easily  be  stripped  from  the  wall  of  the  vein  with- 
out injury.  Occasionally  a  short  vessel  Avill  be  found  extending  directly 
from  the  internal  jugular  vein  to  the  overlying  node  which  will  give 
troublesome  bleeding  if  it  is  cut.  This  may  be  seized  with  a  stitch  and 
a  parietal  ligature  applied.  Care  must  be  taken  not  to  injure  the  spinal 
accessory  nerve  which  emerges  from  the  sterno-mastoid  about  the 
middle,  and  passes  almost  transversely  across  the  triangle  to  enter  the 
trapezius.  A  number  of  enlarged  nodes  are  sometimes  encountered  at 
this  point.  The  thoracic  duct  must  not  be  forgotten  when  operating 
on  the  left  side.  A  thorough  removal  of  all  fat  will  greatly  aid  in 
securing  a  perfect  cure.  c.  g.  d. 


GYNECOLOGY, 

By  REUBEN  PETERSON,  A.  B.,  M.  D.,  Ann  Arbor,  Michigan. 
ntoratsox  or  gthbcologt  and  obstbtxics  in  tmb  ukivbesitt  op  Michigan. 

AND 
CHRISTOPHER  GREGG  PARNALL,  A.  B.,  M.  D..  Ann  Arbor.  Michigan. 

FIRST  ASSISTANT  IN  GTNBCOX.OGT  AND  OMTBTUCS  IN  TMB  UNIVBXSITY  OV  MICHIGAN. 


HAS  EXPERIENCE  SUSTAINED  THE  MORE  RADICAL 
OPERATION  FOR  CANCER  OF  THE  UTERUS? 

Clark  (Surgery,  Gynecology,  and  Obstetrics,  Volume  II,  Number 
II)  reviews  his  experience  in  the  operative  treatment  of  cancer  of  the 
uterus.  Qark,  Rumpf,  and  Ries,  were  among  the  first  to  advocate  the 
extensive  operation  of  removal  of  the  iliac  glands  along  with  the  uterus 
and  appendages.  The  results  of  this  method  have,  however,  been  dis- 
appointing. The  immediate  mortality  is  very  great  and  recurrence  is 
just  about  as  frequent  as  in  other  less  radical  procedures.    There  is  a 


26  ORIGINAL  ABSTRACTS. 

great  difference  of  opinion  between  various  operators  regarding  the 
time  of  metastasis  in  cancer  of  the  cervix.  The  writer  evidently  now 
adopts  the  view  advanced  by  Cullen  and  Winter  that  metastasis  occurs 
comparatively  late  in  the  disease.  When  the  operable  glands  are 
involved  according  to  the  studies  of  Schauta,  only  thirteen  per  cent  show 
no  involvement  of  the  upper  or  nonoperable  glands.  Consequently, 
when  there  is  extension  of  the  cancerous  process  to  the  glands,  the 
outlook  is  not  at  all  hopeful  even  with  a  so-called  radical  operation. 

In  view  of  these  findings,  the  author  now  limits  his  operative  inter- 
ference to  a  thorough  local  extirpation  of  the  uterus  and  adnexa,  includ- 
ing the  upper  portion  of  the  vagina  and  the  greater  part  of  the  broad 
ligaments  and  parametrium.  The  abdominal  route  is  preferred  to  the 
vaginal,  on  account  of  the  better  opportunity  to  get  well  out  on  the 
broad  ligaments.  c.  g.  p. 


OBSTETRICS. 

By  WILLIAM  HORACE  MORLEV,  Ph.  B.,  M.  D.,  Ann  Arbor,  Michigan. 

DBMOMSTRATOR  OF  OBSTBTRICS    AKD    GTNSCOLOCT  IM  TMB  UMITBIUITr  OV  MICHIOAN. 

AND 

WALES  MELVIN  SIGNOR.  M.  D.,  Ann  Arbor,  Michigan. 

ASStSTAMT  IN  OSSTBTRICS  AND  GTNBCOLOGY  IN  THB  UNITBRSITT  OF   MICHIGAN. 


CAESAREAN  SECTION. 


Olshausen  {Zentralblatt  fiir  Gyndkologie,  1906,  Number  I) 
reports  his  results  in  one  hundred  eighteen  cases.  This  report  is  sup- 
plemental to  one  made  by  him  in  1902  {Deutsche  Klinik,  Band  IX),  an 
abstract  of  which  appeared  in  iljt  $^0utan  anb  Surgton  for  February, 
1904,  page  81.  In  his  one  hundred  eighteen  cases  Olshausen  sum- 
marizes the  indications  as  follows: 


Contracted  pelves, 

91  cases 

7      " 
6      " 

4      ** 
4       " 
2       *' 
2       ** 
2       " 

UrCiampsia, 

Myomata, 

Carcinoma  uteri. 

Fixation  of  vagina, 

Nephritis, 

Vitium  cordis. 

Stenosis  of  vagina  and  cervix, 

Among  the  cases  of  contracted  pelves  w^ere  those  of  the  rachitic  type 
most  often  seen.  Seventy-one  of  the  ninety-one  cases  were  due  to 
rachitis.  The  remaining  twenty  cases  were  distributed  as  follows: 
Five  generally  contracted,  five  obliquely  contracted,  two  transversely 
contracted,  two  pseudoosteomalacic,  three  skoliotic,  one  kyphoskoliotic 
and  two  contracted  or  narrowed  from  exostoses.  In  eclampsia  the 
author  prefers  Caesarean  section  to  forceps  or  to  version  and  extraction. 
He  further  states  that  the  use  of  morphia  in  eclamptic  cases  is  danger- 
ous to  the  fetus. 


TREATMENT  OF  DIPHTHERIA.  27 

His  technique  has  not  been  radically  changed  since  his  last  report. 
He  does  not  put  as  much  faith  in  the  course  of  the  round  ligaments  in 
the  determination  of  the  placental  site,  as  he  did  formerly.  It' can 
usually  be  located  from  the  injection  of  the  uterine  wall  and  from  the 
outpouching  of  either  the  anterior  or  posterior  wall.  Hemorrhage  is 
not  to  be  feared  as  it  is  easily  controlled  after  the  cut  edges  of  the 
uterine  wall  have  been  brought  together.  In  seven  patients  this  oper- 
ation was  performed  twice.  In  two  three  times  and  in  three  four  times. 
All  these  cases  recovered.  In  his  ninety-one  cases  of  contracted  pelves 
Olshausen  has  only  lost  nine  cases.  w.  h.  m. 


PEDIATRICS. 

By  ARTHUR  DAVID  HOLMES,  M.  D.,C.  M.,  Detroit,  Michigan. 


THE  UNCERTAINTIES  OF  EARLY  DIAGNOSIS  AND  THE 
NECESSITY  OF  EARLY  AND  VIGOROUS  TREAT- 
MENT OF  DIPHTHERIA. 

McMahon  (Pediatrics,  Number  IV,  1905)  says  the  death-rate  in 
Ontario  as  elsewhere  is  too  high,  and  attaches  much  blame  to  faulty 
or  tardy  diagnosis  and  late  and  half-hearted  treatment.  He  gives  as 
causes  of  failure : 

( 1 )  The  physician's  attention  is  not  especially  directed  to  the  throat 
and  he  fails  to  look  at  it  and  diagnoses  something  else ;  by  the  time  he 
recognizes  his  error,  the  case  is  hopeless.  The  golden  rule  is  "always 
examine  the  throat  of  a  sick  child,  no  matter  what  its  symptoms  are." 

(2)  He  examines  the  throat  and  thinks  he  has  a  case  of  tonsillitis 
or  coryza  or  croup  to  deal  with,  or  that  even  if  it  is  diphtheria  it  is  so 
mild  that  the  old-fashioned  remedies  are  sufficient  for  its  cure. 

(3)  He  fails  to  follow  up  a  suspicious  case  and  finds,  when  too 
late,  that  the  patient  is  in  a  desperate  condition. 

(4)  He  treats  one  amongst  many  children  and  fails  to  protect  the 
others  exposed  to  contagion,  by  a  preventive  injection. 

(5)  He  uses  antitoxin,  but  is  half-hearted  and  does  not  use  enough. 

(6)  In  cases  of  laryngeal  diphtheria  he  uses  antitoxin — perhaps  in 
large  doses — ^but  fails  to  make  an  early  resort  to  accessory  remedies, 
such  as  calomel  fumigation  and  intubation. 

(7)  He  makes  an  early  diagnosis,  but  puts  off  the  injection  of  anti- 
toxin until  tomorrow  or  the  day  after. 

The  author  says  the  diagnosis  of  diphtheria  should  be  made  at  the 
first  visit  if  possible.  He  does  not  believe  we  should  depend  or  wait 
for  a  bacteriological  examination.  In  every  case  in  which  there  is  even 
a  suspicion  of  diphtheria,  give  antitoxin  at  once  and  give  it  freely.  If 
bacteriological  examination  shows  the  presence  of  the  diphtheria 
bacillus,  give  an  injection  to  each  of  the  children  of  the  household  to 
prevent  the  spread  of  infection.     In  laryngeal  diphtheria  the  author 


28  ORIGINAL  ABSTRACTS. 

treats  his  cases  as  follows :  (i)  Inject  antitoxin  (full  doses)  and  fume 
calomel  under  a  tent  (thirty  grams  an  hour)  until  stenosis  is  relieved. 
(3)  Intubate  early  if  symptoms  demand.  To  have  a  low  death-rate 
one  must  be  prompt,  bold  and  fearless  in  his  treatment.  In  specially 
malignant  cases  he  recommends  twenty  thousand  to  thirty  thousand 
units  as  an  initial  dose  injected  into  the  median  basilic  vein. 


ORTHOPEDICS. 

By  IRA  DEAN'LOREE,  M.D.,  Ann  Arbor,  Michigan. 

FIRST  ASSISTAMT  IN  ftVSGBRY  IN  THB  UNIVBRSITY  OV   MICHIGAN. 


A  CASE  OF  EXCISION  OF  THE  HEAD  OF  THE  HUMERUS 
FOR  CONGENITAL  SUBACROMIAL  DISLOCA- 
TION OF  THE  HUMERUS. 

John  B.  Roberts,  M.  D.,  of  Philadelphia  (American  Journal  of 
the  Medical  Sciences,  December,  1905).  His  patient  was  a  boy  age 
three  years  who  came  to  operation  December  5,  1903.  The  condition 
present  was  as  follows:  The  head  of  the  left  humerus  could  be  felt 
under  the  acromial  process.  The  humerus  was  firmly  abducted  with 
the  external  condyle  pointing  forward.  The  elevation  of  the  arm, 
so  far  as  voluntary  movement  was  concerned,  was  impossible  and 
other  movements  restricted.  He  therefore  decided  to  replace  the  head 
by  operation,  resecting  the  head  for  false  joint  providing  the  former 
method  failed. 

A  vertical  incision  was  made  over  the  prominence  of  the  head 
below  the  acromion  and  the  capsule  opened.  As  the  attempt  failed,  a 
second  incision  on  the  front  of  the  shoulder  was  made  and  carried 
down  to  the  deep  layer  of  muscles.  Combined  efforts  from  the  two 
points  gave  no  results. 

He  concluded  that  only  a  bloody  and  prolonged  dissection  would 
expose  the  glenoid  fossa;  even  if  reduction  resulted  he  might  obtain 
only  a  stiff  joint,  which  was  no  better  than  the  original  deformity; 
that  excision  of  the  head  would  give  as  good,  if  not  a  better  joint,  with 
less  risk. 

The  bone  was  sawed  close  to  the  head  but  in  its  removal  the  long 
head  of  the  biceps  was  severed.  Both  cuts  were  closed  without  drain- 
age and  the  forearm  supported  by  a  sling. 

Examination  June  i,  1905.  The  left  arm  was  three-quarters  inch 
shorter  than  the  right  arm.  Grating  at  the  false  joint  with  passive 
motion.  Rotation  not  so  complete  as  on  right  side.  Elevation  of  the 
humerus  restricted  and  scapula  moves  with  it,  if  passive  movement 
is  extensive.  Humerus  still  rotates  slightly  forward.  The  patient 
can  touch  the  back  of  his  ear  and  neck  on  the  left  side,  put  his  hand 
to  his  mouth,  and  can  clasp  his  hands  behind  his  back  in  the  lumbar 
region.  The  belly  of  the  biceps  stands  out  prominently  in  the  middle 
of  the  arm  due,  no  doubt,  to  the  division  of  its  long  head.    He  cannot 


SUBSTITUTES  FOR  NITRATE  OF  SILVER.  29 

lift  the  left  hand  over  his  head  but  could  merely  touch  the  occipital 
region.  He  could  put  the  left  hand  on  the  opposite  shoulder  and  bring 
the  elbow  nearly  in  contact  with  the  ribs. 

Doctor  Roberts  thinks  a  large  proportion  of  these  cases  result  from 
intrauterine  causes  as  many  times  they  occur  on  both  sides  in  the  same 
patient  and  in  more  than  one  child  of  the  same  family. 


OPHTHALMOLOGY. 

By  WALTER  ROBERT  PARKER.  B.  S..  M.  D.,  Detroit.  Michigan. 

PROFBSSOR  OF   OPHTBAUfOLOGT   IN  TMB  UNIVBIISITY  OF   MICHIGAN. 


PROTARGOL  AND  ARGYROL  AS  SUBSTITUTES  FOR 
NITRATE  OF  SIVER. 

Doctor  G.  E.  de  Schweinitz  (Ophthalmic  Record,  January,  1906) 
expresses  his  views  concerning  the  use  of  the  newer  salts  of  silver. 

At  one  time  this  writer  had  employed  protargol  very  freely  as  a 
substitute  for  nitrate  of  silver  but  had  found  it  comparatively  unsatis- 
factory and  had  abandoned  its  use.  He  had  employed  argyrol  first  as 
a  substitute  for  nitrate  of  silver  in  all  forms  of  conjunctivitis,  except 
diplobacillus  conjunctivitis,  in  the  treatment  of  purulent  conditions  of 
the  lachrymonasal  passages,  in  the  management  of  infected  cervical 
ulcerations,  and  in  the  preparation  of  the  conjunctival  sac  prior  to 
operations.  In  his  earlier  experiences  he  had  been  inclined  to  think 
argyrol  was  a  satisfactory  substitute  for  nitrate  of  silver  in  various 
conjunctival  inflammations,  and  particularly  in  ophthalmia  neonatorum, 
but  within  the  last  year  he  had  met  with  so  many  cases  wherein  it  had 
been  necessary  to  abandon  this  agent  and  substitute  nitrate  of  silver, 
that  his  faith  in  the  remedy  had  been  seriously  shaken. 

The  doctor  was  satisfied  that  nitrate  of  silver  properly  applied  in 
gonorrheal  conjunctivitis  of  newborn  babies  and  in  gonorrheal  conjunc- 
tivitis of  adults  frequently  was  a  more  satisfactory  remedy,  although 
he  recognized  its  many  disadvantages.  He  had  been  accustomed  to 
employ  argyrol  by  the  so-called  immersion  method,  and  continued  so  to 
use  it  in  certain  cases,  but  not  to  the  exclusion  of  nitrate  of  silver.  He 
thought  the  plan  advocated  by  Bruns,  that  after  its  use  for  a  few  days 
nitrate  of  silver  should  be  applied  once  a  day  by  the  surgeon,  and  in 
the  meantime  the  conjunctiva  should  be  kept  flushed  with  argyrol,  a 
good  one.  In  many  cases  of  gonorrheal  conjunctivitis  he  did  not 
believe  that  of  itself  it  was  as  safe  a  remedy  as  nitrate  of  silver,  and  in 
a  certain  number  of  cases  it  failed  completely  and  nitrate  of  silver  had 
to  be  substituted.  He  continued  to  find  argyrol  useful  as  an  adjunct 
in  many  forms  of  conjunctivitis,  particularly  of  mild  type,  and  thought 
it  a  satisfactory  remedy  for  irrigating  the  lachrymonasal  passages  if 
purulent  discharge  was  present.  He  also  continued  to  use  it  in  cleaning 
the  conjunctiva,  if  there  was  hyperemia  or  slight  discharge,  preparatory 
to  operations  on  the  globe.    Taking  his  experience  as  a  whole,  he  was 


30  ORIGINAL  ABSTRACTS. 

satisfied  that  neither  protargol  nor  argyrol  represents  in  any  sense  a 
satisfactory  substitute  for  nitrate  of  silver  in  gonorrheal  affections  of 

the  conjunctiva. 

*       *       *  . 

Note. — To  use  nitrate  of  silver  to  its  best  advantage  requires  per- 
haps more  skill  and  careful  observation  than  the  use  of  any  single  drug 
in  the  armamentarium  of  the  opththalmic  surgeon;  while  nothing  is 
more  simple  than  the  directions  for  use  of  its  substitutes.  When  prop- 
erly used,  nitrate  of  silver  still  holds  its  supremacy.  Our  experience  in 
the  University  clinic  is  in  exact  accord  with  that  of  Doctor  de  Schwei- 
nitz. 


OTOLOGY. 

By  R.  bishop  CANFIELD.  A.  B..  M.  D.,  Ann  Arbor,  Michigan. 

PKOVBSSOR  OF  OTOLAKYNCOLOGY  IN  THE  UNIVBRSITY  OF  MICHIGAN. 
AND 

WILLIAM  ROBINSON  LYMAN.  A.  B.,  M.  D.,  Ann  Arbor.  Michigan. 

DBMONSTKATOR  OF  OTOLARYNGOLOGY  IN  TKB  UNIVBRSITY  OF  MICIIIGAN. 


A  REPORT  OF  TWO  CASES  OF  MASTOIDECTOMY  SINUS 

THROMBOSIS. 

McKernon  (Archives  of  Otology,  Volume  XXXIV,  Number  IV). 
The  first  case  was  a  male  twenty-six  months  old,  always  healthy  save 
for  an  attack  of  acute  otitis  one  year  before.  When  first  examined 
there  was  a  mucopurulent  discharge  in  the  external  auditory  canal, 
examination  of  which  showed  staphylococcus  infection.  The  tympanic 
membrane  was  bulging  and  there  was  a  small  perforation  in  the 
posterior  quadrant.  The  temperature  was  102°  and  the  child  was 
rather  drowsy.  The  t)mipanic  membrane  was  incised  and  in  twelve 
hours  the  temperature  was  100''.  On  the  fifth  day  temperature  rose  to 
103.2°  and  there  were  signs  of  mastoid  involvement.  The  mastoid 
was  opened  and  a  small  amount  of  pus  found  in  the  antrum.  For 
several  days  the  patient  did  well  and  the  wound  looked  healthy  except 
in  a  small  spot  over  the  sigmoid  groove  in  the  region  of  the  knee. 
The  temperature  was  103°,  the  child  restless  and  refusing  nourishment. 
The  temperature  the  following  day  was  104.8°  and  the  wound  was 
bathed  in  pus.  A  diagnosis  of  sinus  involvement  was  made,  the  sinus 
was  opened  and  a  clot  removed,  free  hemorrhage  obtained  and  the 
child  apeared  stronger.  For  four  days  the  temperature  ranged  between 
103°  and  100°.  On  the  fifth  day  the  temperature  went  to  104.2°.  The 
child  was  very  restless  and  looked  septic.  A  few  hours  later  the  hands 
and  feet  became  cold,  the  temperature  reached  105°  ;  pulse  160.  The  vein 
was  ligated  below  the  clavicle  and  resected  to  its  exit  from  the  skull. 
It  was  found  to  contain  a  clot  for  nearly  an  inch  below  the  skull.  The 
facial  vein  was  also  involved  and  nearly  an  inch  was  resected.  The 
wound  closed  and  patient  made  an  uninterrupted  recovery. 


DRAINAGE  OF  THE  FAUCIAL  TONSILS.  31 

The  second  case  was  a  female,  age  thirty,  who  ckveloped  an  acute 
otitis  twenty-four  hours  after  a  partial  turbinectomy  with  symptoms 
of  a  profound  systemic  infection.  The  tympanic  membrane  which  was 
bulging  was  incised.  The  discharge  showed  many  streptococci  and  a 
few  pneumococci.  The  temperature  was  102.2°  and  the  mastoid  tender. 
The  temperature  remained  about  the  same  and  on  the  third  day  the 
mastoid  was  opened  and  found  to  be  involved  throughout.  Within  a 
few  hours  there  was  a  sudden  rise  of  temperature  to  103.8°  and  a 
sudden  fall  to  98.4°.  For  six  days  the  patient  did  well  save  for  a  slight 
fluctuation  of  temperature.  On  the  tenth  day  there  was  a  sudden  rise 
to  103.8°  with  intense  headache  and  marked  variations  of  temperature 
during  the  next  twenty-four  hours.  Sinus  involvement  was  diagnosed 
but  owing  to  the  extreme  weakness  ol  the  patient  operation  was  delayed 
and  stimulating  treatment  given  for  five  days.  On  the  sixth  day  the 
sinus  was  opened,  and  a  large  clot  found  extending  backwards  from 
the  knee  about  two  inches.  In  the  lower  part  of  the  vein  there  was 
disintegrated  clot  and  pus.  There  the  internal  jugular  was  exposed, 
ligated  and  resected.  At  the  same  time  many  suppurating  glands  were 
renK)ved,  the  wound  was  sutured  and  the  patient  made  a  good  recovery. 
All  specimens  removed  contained  numerous  streptococci.  It  is  worthy 
of  note  that  in  this  case  there  were  no  chills,  nausea,  or  vomiting. 

From  the  subsequent  history  of  the  first  case  it  is  seen  that  it  would 
have  been  wiser  to  have  resected  the  vein  at  the  time  the  sinus  was 
opened,  as  there  may  be  free  hemorrhage  at  the  bulb  while  the  vein  in 
the  neck  still  contains  a  thrombus.  Doctor  McKernon  feels  like  ligating 
the  vein  in  all  cases  at  the  time  of  operation  when  the  condition  of  the 
patient  will  allow.  r.  b.  c. 

LARYNGOLOGY. 

By  WILLIS  SIDNEY  ANDERSON,  M.  D.,  Detroit.  Michigan. 
AmsTAirr  to  tub  cmair  ow  lastnooloot  in  thb  dbtkoit  collboi  ow  mbdicini 


THE  LYMPHATIC  DRAINAGE  OF  THE  FAUCIAL 
TONSILS. 

George  Bacon  Wood  (American  Journal  of  the  Medical  Sciences, 
August,  1905)  has  made  a  number  of  dissections  of  injected  specimens 
to  show  the  Ijmiphatic  drainage  of  the  faucial  tonsils.  The  fate  of 
microorganisms  which  have  entered  the  parenchyma  of  the  tonsils  is 
dependent  upon  two  factors :  First,  the  pathogenic  potency  of  the  germ 
itself,  and  second,  the  vital  resistance  offered  by  the  tissues  to  its 
invasion.  It  has  been  proven  that  foreign  bodies  in  the  crypts  can  pass 
through  the  epithelium  into  the  interfoUicular  tissue.  The  absorption 
is  probably  due  to  the  action  of  the  muscles  and  the  presence  of  the 
lymph  current. 

'  The  author  describes  the  different  lymphatic  chain  of  glands  and 
gives  the  regions  they  drain.    The  direction  of  the  drainage  from  the 


32  ORIGINAL  ABSTRACTS. 

tonsils  as  established  by  the  study  of  the  injected  specimens  is  as 
follows : 

"The  lymph  vessels  pass  from  the  external  portion  of  the  tonsil 
through  the  peritonsillar  connective  tissue,  the  pharyngeal  aponeurosis, 
and  the  superior  constrictor  of  the  pharynx,  and  one,  two  or  more 
fine  vessels  run  obliquely  in  a  downward,  posterior,  and  outward  course, 
passing  below  the  facial  artery.  Bending  more  posteriorly  the  lymph 
vessels  next  run  between  the  internal  jugular  vein  and  the  stylohyoid 
muscle,  reaching  finally  the  superior  surface  of  an  enlarged  lymph 
gland,  placed  just  beneath  the  anterior  border  of  the  sterno-cleido~mas- 
toid  muscle,  where  it  is  crossed  by  the  posterior  belly  of  the  digastric 
muscle.  The  efferent  vessels  from  this  gland  are  generally  two  or  three 
in  number,  and  pass  into  the  neighboring  glands  of  the  internal  jugular 
group.  Further  anastomoses  which  connect  the  lower  glands  of  the 
internal  jugular  group  with  those  receiving  the  tonsillar  drainage  form 
a  complete  lymph  channel,  through  which  tonsillar  lymph  finally  empties 
into  the  jugular  lymph  trunk." 

The  author  gives  the  name  "tonsillar  lymph  gland"  to  the  gland 
placed  external  and  slightly  anterior  to  the  internal  jugular  vein,  and  is 
embedded  in  loose  areolar  tissue  containing  more  or  less  fat.  This 
gland  is  especialy  involved  in  infections  from  the  tonsil. 


DERMATOLOGY. 

By  WILLIAM  FLEMING  BREAKEY.  M.  D.,  Ann  Arbor.  Michigan. 

CLINICAL  PROFBSSOR  OP  DIRMATOLOGT  AMD  STPHILOLOGT  IN  THB  UNIVBKtITY  OP   MICHIGAN. 


ON  THE  INFLUENCE  OF  LIGHT  IN  THE  PRODUCTION  OF 
CANCER  OF  THE  SKIN. 

Doctor  James  Nevins  Hyde,  of  Chicago,  Professor  of  Diseases  of 
the  Skin  in  Rush  Medical  College,  read  a  paper  on  this  subject  before 
the  Ann  Arbor  Medical  Qub,  November  8,  1905.  The  entire  article  is 
published  in  the  American  Journal  of  the  Medical  Sciences  for  January, 
1906,  but  the  following  abstract  presents  the  salient  points  thereof. 

The  paper  was  a  comprehensive  discussion  of  the  pathology,  etiol- 
ogy, prevalence,  and  mortality  resulting  from  conditions  beginning  as 
cancer  of  the  skin,  particularly  with  reference  to  the  damaging  effects 
of  solar  light  and  :r-rays  under  certain  conditions,  and  radiotherapy  in 
general ;  also  to  the  lesser  prevalence  and  death  rate  from  cancer  in  the 
colored  races  and  inhabitants  of  warmer  countries,  attributed  to  the 
protection  against  ill  effects  of  excessive  light,  afforded  by  the  greater 
pigmentation  of  the  skin. 

It  is  impossible  to  give,  in  the  limits  available,  an  adequate  abstract 
of  the  scope  and  value  of  the  paper,  illustrated  with  several  paintings 
and  maps,  supported  by  statistics,  and  presented  in  the  interesting  and 


CANCER  OF  THE  SKIN.  33 

forcible  style  of  the  distinguished  author.  It  should  be  read  in  full  to 
be  appreciated. 

Discussing  the  various  forms  of  epitheliomata,  "these  all  represent 
variations  of  a  single  morbid  process  ...  an  invasion  of  neigh- 
boring tissues  through  the  avenue  of  the  lymphatic  spaces  by  epithelial 
cells."  Considering  the  causes  of  this  change,  which  may  reach  a  point 
when  destruction  of  life  results,  and  noting  the  recent  research  work 
on  the  subject  conducted  by  scientific  men  in  laboratories  equipped  and 
maintained  by  generous  private  and  public  benefactions,  "as  yet,  how- 
ever, agreement  has  not  been  reached  respecting  the  essential  factors 
in  the  genesis  of  this  scourge  of  the  human  family." 

"The  chief  causes  of  cancer  heretofore  assigned  by  writers  on  the 
subject  may  be  classed  as  follows :  First,  proliferation  of  the  epidermis 
proceeding  from  stray  bits  of  the  germinal  layer  separated  in  the  embryo 
from  their  proper  attachments  and  included  in  the  growing  tissues 
(Cohnheim)  ;  second,  loss  of  equilibrium — ^pressure  and  counterpres- 
sure — ^between  the  epidermis  and  the  corium;  third,  disturbance  of 
equilibrium  between  waste  and  repair;  fourth,  congenital  tendency  to 
reversion  of  epidermal  cells  to  a  simpler  and  undifferentiated  type ;  fifth, 
parasitism."    There  are  many  and  seductive  reasons  for  searching  for 

a  parasite  as  the  cause  of  cancer It  is  difficult  to  conceive 

that  the  human  body  in  so  large  a  proportion  of  cases,  without  intro- 
duction of  a  foreign  element,  can  evolve  a  growth  of  such  malignant 

potency A  decided  reaction,  however,  seems  to  have  set 

in  against  the  tide  which  bore  in  the  direction  of  parasitism  of  cancer. 

.  .  Many  of  the  bodies  which  it  was  once  believed  would  prove  to 
be  parasites  are  now  known  to  be  irregular  cell  inclusions.  .  .  . 
Various  considerations,  which  need  not  be  cited  in  full,  have  for  the 
time  lessened  the  belief  of  scientific  men  in  the  hypothesis  of  parasitism 
in  cancer. 

"Carcinoma  of  the  sailor's  skin,"  also  described  by  Unna,  in  which 
cases  the  ears,  the  cheeks,  the  temples,  the  backs  of  the  hands,  and  of 
the  fingers  first  become  mottled  and  pigmented,  nonpigmented  islands 
of  skin  later  developing  between  the  freckles,  with  thickening,  roughen- 
ing, and  comification  of  the  horny  layer  follow,  and  eventually,  as  in 
xeroderma  pigmentosum,  the  sebaceous  glands  become  hypertrophied 
and  indolent  cancerous  growths  of  the  "rodent  ulcer"  type  form.  There 
is  both  hyperkeratosis  and  acanthosis,  and  conical  homy  taps  push 
downward  into  the  corium;  the  lymph  spaces  of  the  lattei^ become 
largely  dilated ;  the  mast  cells  multiply,  fissures  form,  and  finally  papil- 
lary cancerous  growths  furnish  flabby  ulcers  which  refuse  to  heal. 

These  instances  of  malignant  cancer  occurring  obviously  as  a  result 
of  exposure  to  light  justify  the  inquiry  whether  all  cutaneous  cancers 
are  not  influenced  in  their  origin  and  career  by  the  actinic  rays.  It 
would  be  venturesome  without  strong  proof  to  make  a  broadly  affirma- 
tive answer  to  such  a  question ;  but  the  condition  of  skin  which  makes 
epithelioma  more  than  possible  certainly  predisposes  to  its  occurrence. 


34  ORIGINAL  ABSTRACTS. 

The  question  can  be  better  put  by  asking  whether  actinic  rays  of  light 
unfavorably  influence,  not  all,  but  certain  sensitive  skins  at  definite 
ages  of  the  body  in  the  direction  of  the  epitheliomatous  metamorphoses? 

It  is  to  be  remembered  that  pigmentation,  especially  hyperpigmenta- 
tion,  admittedly  furnishes  a  valuable  protective  screen  for  the  body. 
The  dark  skins  of  the  Asiatic  and  the  African  possess  for  them  a  great 
protective  value  against  heat  and  light.  The  Albino,  without  trace  of 
pigment  either  in  the  skin  or  the  choroid  coat  of  the  eye,  is  notoriously 
feeble  of  body  and  short-lived.  Hektoen  states  that  black  rats  are  more 
resistant  than  gray,  and  gray  rats  than  white  to  anthrax.  In  this  con- 
nection it  is  interesting  to  note  that  Gaylord  and  his  colleagues  in  study- 
ing Jensen's  adenocarcinoma  obtained  their  remarkable  results  after 
experimentation  with  white  mice  only.  The  researches  of  Loeb,  Gru- 
ber,  Dubois  and  others  on  the  orientation  of  plants  and  animals  throw 
some  light  on  this  question.  They  indicate  that  heliotropism  is  influ- 
enced largely  by  the  more  refrangible  rays  of  light;  .  .  .  that  at 
a  constant  intensity  light  operates  as  a  continuous  source  of  stimulation ; 
.  .  .  chemical  rays  playing  upon  the  sensitive  and  unprotected  skin 
produce  in  order — first,  hyperemia;  second,  pigmentation;  third,  atro- 
phy ;  fourth,  cancerosis.  The  first  two  changes  are  obviously  protective 
in  character. 

The  action  of  the  Finsen  light  upon  the  skin  produces  a  reactive 
hyperemia,  though  the  technique  of  its  application  requires  that  the 
area  to  be  treated  should  be  made  as  exsanguine  as  possible  to  permit 
the  passage  of  rays  to  the  skin.  The  action  of  the  ,r-rays  upon  the 
cutaneous  surface  is  similar  to  that  of  the  ultraviolet  frequencies. 
.  .  .  The  hyperemia  is  followed  by  well-marked  pigmentation,  more 
conspicuous  in  some  cases  than  in  others.  Later,  in  the  results  of 
actinic  ray  bombardment,  atrophy  may  result,  the  overstimulated  pro- 
toplasm losing  its  vitality,  the  cells  and  their  nuclei  shrinking  while 
phagocytosis,  as  in  other  cases,  disposes  of  the  epithelial  cells.  But 
hyperkeratosis,  and  finally  cancerosis  may  occur.  The  .r-ray  produc- 
tion of  cancer  of  the  skin  reported  by  Mendes,  Da  Costa,  White, 
Bowen,  Pusey  and  others  is  established  by  other  incontrovertible  evi- 
dence. Fortunately  the  beneficent  use  of  the  rays  far  outranks  the 
exceptional  catastrophe  in  which  a  disastrous  result  is  produced. 
Doctor  Ormsby  has  noticed  that  patients  who  burn  in  sunlight  are 
burned  by  ^-rays.  The  beneficial  effects  of  all  these  rays  occur  when 
the  stimulation  is  pushed  to  the  point  of  cell  shrinkage  and  not  farther. 

The  doctrine  that  light  is  capable  of  exciting  in  animal  tissue  a 
series  of  changes  which  may  terminate  fatally  is  not  inconsistent  with 
the  facts  of  science.  Beneficent  as  they  are  shown  to  be  in  much  that 
relates  to  both  the  genesis  and  conservation  of  life,  heat,  light,  and 
electricity,  interchangeable  modes  of  motion  have  each  a  stroke  where- 
with slowly  or  swiftly  they  may  destroy  that  life." 

Following  are  the  doctor's  conclusons : 

(i)  The  skin  of  the  human  body  in  a  certain  proportion  of  indi- 


DIET  IN  EPILEPSY.  35 

viduals,  and  in  those  only,  is  hypersensitive  to  the  action  of  the  actinic 
rays  of  the  spectrum. 

(2)  This  hypersensitiveness  may  be  exhibited  in  the  production  of 
either  hyperemia,  pigmentation,  telangiectasis,  atrophy,  hyperkera- 
tosis, or  cancerosis  of  the  skin,  or  by  all  at  times  in  a  determined  order 
of  succession. 

(3)  In  the  form  of  childhood  cancerosis,  known  as  xeroderma  pig- 
mentosum, pigmentation,  telangiectasis,  atrophy,  hyperkeratosis,  and 
cancerosis  of  the  skin  resulting  from  exposure  to  rays  of  light,  are 
exhibited  early  in  life,  instances  of  this  disorder  being  exceedingly  rare. 

(4)  Pigmentation,  telangiectasis,  atrophy,  hyperkeratosis,  and  can- 
cerosis of  the  skin  occur  in  adults  much  more  frequently  than  in  child- 
hood, reaction  to  the  play  of  actinic  rays  of  light  upon  the  surface  being 
chiefly  determined  after  the  middle  periods  of  life  have  been  reached. 

(5)  Physiological  pigmentation  of  the  skin  in  the  colored  races 
seems  to  furnish  relative  immunity  against  cancerosis  of  that  organ. 

(6)  The  colored  races  apparently  suffer  less  than  the  whites  from 
cancer  of  other  organs  than  the  skin.  This  relative  immunity  may  be 
due  to  the  protection  from  actinic  rays  of  light  furnished  by  the  pig- 
ment of  the  integument. 


NEUROLOGY. 

By  DAVID  INGLIS,  M.  D..  Detroit,  Michigan. 

PROFISSOS  or  KIRVOUS  AND  KBNTAL  DISHASSS  IN  THB  DBTKOIT  COLLBCB  OF  MBDICINB. 

AND 

IRWIN  HOFFMAN  NEFF,  M.  D.,  Pontiac.  Michigan. 

ASSISTANT  PHYSICIAN  AT  THB  BASTBRN  MICHIGAN  ASYLUM. 


THE  DIET  IN  EPILEPSY. 


RoSANOFF  (Journal  of  Nervous  and-  Mental  Disease,  December, 
1905,  Volimie  XXXII,  Number  XII).  The  writer  quotes  authorities 
in  proof  that  certain  articles  of  diet  may  cause  a  material  change  in  the 
syndrome  of  epilepsy.  The  paper  is  founded  on  eleven  cases.  The 
results  were  obtained  from  five  experiments,  a  definite  number  of 
epileptics  being  placed  on  a  prescribed  diet,  and  accurate  clinical 
observations  taken. 

His  results  are  summed  up  as  follows :  "Experiments  one  and  two 
proved  that  the  effect  of  a  mixed  diet  in  epilepsy  differs  in  no  way 
from  that  of  a  vegetable  diet  containing  the  same  quantities  of  proxi- 
mate principles.  Consequently  any  lingering  belief  that  animal  iood 
has  any  effect  as  such  is  to  be  definitely  discarded.  Experiments  three 
and  four  prove  that  the  quantity  of  proteids  in  the  diet  has  a  decided 
influence  on  the  manifestations  of  epilepsy.  If  it  i<'  either  above  or 
below  the  indispensable  minimum  the  severity  of  the  disease  is 
increased.  Experiment  five  shows  that  if  the  diet  of  an  epileptic  is 
made  to  contain  a  large  excess  of  proteid  and  practically  no  carbohy- 


36  ORIGINAL  ABSTRACTS. 

drates,  so  that  the  organism  is  compelled  to  use  proteid  material  in 
place  of  carbohydrate  material,  the  number  of  convulsions  increases 
enormously  and  there  is  a  general  aggravation  in  the  physical  and 
mental  condition  of  the  patient." 

In  conclusion  the  author  advances  a  theory  as  follows :  "That  just 
as  the  organism  of  the  diabetic  is  unable  to  properly  utilize  carbohy- 
drates, so  the  organism  of  the  epileptic  cannot  take  care  of  proteid 
material  as  it  is  taken  care  of  by  the  normal  organism." 

The  therapeutic  indication,  he  believes,  is  clear,  and  he  expresses 
it  as  follows :  "Carbohydrates  and  fats  are  to  a  certain  extent  capable 
of  replacing  the  proteids  in  the  diet.  The  epileptic  j)atient,  then,  should 
receive  the  largest  amount  of  carbohydrates  and  fats  that  he  can 
assimilate  without  inconvenience,  and  the  smallest  amount  of  proteids 
which  is  compatible  with  the  preservation  of  the  nitrogenous  equi- 
librium ;  that  is  to  say,  the  amount  of  nitrogen  ingested  with  the  food 
must  not  be  allowed  to  fall  below  the  amount  excreted,  for  then  the 
thing  is  overdone,  a  condition  of  proteid  starvation  is  established,  the 
general  health  of  the  patient  suffers,  and  his  disease  becomes 
aggravated."  i.  h.  n. 

THERAPEUTICS. 

By  DELOS  LEONARD   PARKER,  Ph.  B.,  M.  D..  Detroit,  Michigan. 

LBCnmiR  OH  MATBRIA  MBDICA  IN  THB  DBTROIT  COLLBGB  or  MBDICIMB. 


THE  PRESENT  STATUS  OF  SERUM  THERAPY. 

Ezra  Read  Larned,  M.  D.,  in  The  Therapeutic  Gazette  for  Sep- 
tember, 1905,  discusses  the  subject  of  serum  therapy.  He  first  sepa- 
rates the  different  sera  into  two  groups  as  follows :  '  Curative  sera  and 
diagnostic  sera.  He  further  classifies  sera  according  to  their  efficacy 
as  curative  agents. 

In  the  first  group  he  places  those  whose  efficacy  has  been  demon- 
strated beyond  reasonable  doubt,  such  as  antidiphtheric,  antitetanic, 
antiplague,  antistreptococci  and  serum  for  exophthalmic  goitre. 

In  the  second  group  are  sera  whose  value  appears  likely  or  possible, 
but  in  support  of  which  there  is  not  yet  sufficient  evidence  to  warrant 
their  inclusion  in  Class  I.  These  contemplate  hay-fever,  antityphoid, 
antitubercle,  antirabic,  and  antivenene  sera,  and  tuberculin. 

In  the  third  group  are  those  sera  whose  value  is  questioned  by  a 
majority  of  observers.  These  are  antipneumococcic  sera,  antiscarla- 
tina  sera,  antidysenteric  sera,  antivarioloid  sera,  antitoxin  for  cerebro- 
spinal meningitis,  serum  for  rheumatism,  serum  for  syphilis,  and  sera 
for  anthrax,  cancer,  and  leprosy. 

Of  the  curative  sera  Doctor  Lamed  states  that  antidiphtheric  serum 
justly  holds  the  highest  place,  and  if  used  early  and  in  sufficient  quan- 
tities can  be  counted  on  to  overcome  every  case  of  the  disease. 

Of  antistreptococcic  serum  not  so  much  can  be  said.     On  the  whole 


CLINIC  IN   PSYCHIATRY.  37 

the  Doctor  thinks  the  result  obtained  from  this  serum  has  been  dis- 
appointing. This  result  may  be  caused  by  the  circumstance  that  pure 
streptococcic  infection  is  rare  as  compared  with  mixed  infection.  Where 
the  infection  has  been  purely  streptococcic  the  result  has  been  good. 

Antitetanic  serum  gives  good  results  when  used  early  and  in  large 
quantities.  Professor  Ehrlich  is  quoted  as  saying  that  initial  doses  of 
thirty  cubic  centimeters  or  more  followed  by  frequent  subsequent  doses 
of  ten  or  twenty  cubic  centimeters  may  be  depended  on  to  produce 
results  satisfactory  in  character.  Authorities  differ  as  to  the  mode  of 
administering  this  serum.  Among  the  methods  mention  is  made  of 
subcutaneous,  intravenous,  intraneural,  intracerebral  and  intraspinal 
by  lumbar  puncture.  The  use  of  dried  antitetanic  serum  as  a  dusting 
powder  in  dressing  suspected  wounds  is  recommended. 

Antiplague  serum  is  said  to  be  of  positive  value  when  given  in  large 
doses — from  sixty  to  one  hundred  and  fifty  cubic  centimeters,  or  even 
three  hundred  cubic  centimeters,  preferably  intravenously. 

In  exophthalmic  goitre  the  specific  seruhi  is  said  to  be  so  encourag- 
ing in  results  that  its  use  is  to  be  recommended. 

Hay-fever  serum  the  doctor  thinks  is  of  great  but  of  uncertain 
value.  The  remedy  may  be  administered  hypodermically  but  better 
results  are  usually  obtained  by  having  the  patient  himself  apply  the 
serum  to  the  nasal  mucous  membrane  by  means  of  a  dropper  when 
irritation  is  noticed.  In  the  use  of  this  serum  the  good  effects  are  not 
long  maintained. 

Tuberculin  is  spoken  of  as  an  experimental  product  and  antitubercle 
serum  as  being  worthy  of  more  extended  trial.  Serum  for  rheuma- 
tism, secured  from  horses  treated  with  streptococci,  isolated  from  the 
throat  of  the  rheumatic  sufferer,  gives  promise  of  being  valuable. 

The  sera  whose  standing  as  curative  agents  has  not  been  established 
are  mentioned  above. 


EDITORIAL  COMMENT. 


THE  NEW  CLINIC  IN  PSYCHIATRY  AT  THE  UNIVERSITY 

OF  MICHIGAN. 

The  first  University  Psychopathic  Hospital  and  Clinic  established 
in  America  for  the  observation,  care,  and  treatment  of  persons  afflicted 
with  incipient  insanity,  and  for  borderland  cases  which  cannot  be  strictly 
regarded  as  insane,  although  manifesting  various  phases  of  mind  dis- 
turbance, is  now  in  operation  as  a  component  part  of  the  medical  equip- 
ment of  the  University  of  Michigan,  under  the  directorship  of  Doctor 
Albert  Moore  Barrett,  late  pathologist  of  the  Massachusetts  Hospital 
for  the  Insane,  located  at  Danvers,  and  assistant  in  neuropathology  in 
the  Harvard  Medical  School.     The  governing  power  of  the  institution 


38  EDITORIAL  COMMENT. 

is  vested  in  a  joint  committee,  whose  appointment  rests  with  the  Univer- 
sity Regents  and  the  executive  bodies  of  the  various  state  asylums  for 

the  insane. 

♦  *    * 

The  institution  was  created  by  enactment  of  the  legislature  of  190 1. 
A  supplementary  act  of  the  legislature  of  1905  established  relationship 
between  the  hospital  and  asylums,  and  henceforth  the  two  forces  will 
render  combined  service  in  the  management  of  the  new  institution. 
Another  provision  of  the  law  invests  the  director  of  the  Psychopathic 
Hospital  with  the  title  of  pathologist  to  the  several  asylums,  and  pro- 
fessor of  neuropathology  in  the  medical  department  of  the  University. 
In  the  capacity  of  pathologist  a  requirement  contemplates  definite 
knowledge  by  this  official  concerning  the  medical  conduct  of  the 
asylums  throughout  the  state,  exacting  frequent  visits  for  the  purpose 
of  encouraging  the  medical  staffs  to  pursue  careful  scientific  study  of 
the  various  forms  of  mental  disease  peculiar  to  the  inmates.  As  pro- 
fessor in  the  University  the  director  is  required  to  impart  instruction 
in  clinical  psychiatry  and  conduct  the  laboratory  for  psychopathic 
research  which  was  founded  in  connection  with  the  hospital,  the  main- 
tenance of  which  is  insured  by  an  annual  appropriation  of  five  thousand 
dollars  granted  by  the  legislature. 

m     n^    m 

The  objects  sought  to  be  attained  by  founding  the  institution  con- 
template more  accurate  investigation  relative  to  the  nature  and  causes 
of  insanity.  The  idea  is  to  make  the  new  acquisition  a  central  patho- 
logic institute  which  will*  afford  not  only  expert  skill  in  nervous  diseases 
by  reason  of  cooperation  with  the  asylums  of  the  state,  but  possess, 
in  consequence  of  University  connection,  the  additional  advantage  of 
specialists  in  every  branch  of  medicine.  It  will  give  asylum  physicians 
opportunity  to  pursue  research  work  at  the  clinical  laboratory,  and 
qualify  students  to  render  intelligent  service  as  asylum  physicians  or 
general  practitioners.  It  will  exert  influence  in  the  direction  of  cre- 
ating a  correct  public  sentiment  regarding  psychopathic  ailments  and 
of  promoting  rational  ideas  concerning  the  prevention  of  such  diseases. 

*  4t       :|c 

The  Psychopathic  Hospital  is  especially  designed  and  equipped  for 
the  study  of  acute  cases  of  mental  disturbance.  It  has  accommodation 
for  forty  patients — twenty  of  each  sex.  This  limited  number  permits 
the  alienists  to  exercise  close  observation  of  every  subject  committed 
for  treatment.  The  clinical  laboratory  affords  apparatus  for  conducting 
elaborate  investigation  bearing  on  the  phenomena  of  mental  disease, 
and  the  study  of  any  anatomical  material  supplied  by  the  various 
asylums  will  be  pursued  according  to  methods  afforded  by  the  most 
modern  neuropathological  technic.  There  will  likewise  be  installed  in 
the  building  a  complete  hydrotherapeutic  apparatus  modeled  after  the 
design  of  Doctor  Baruch,  together  with  apparatus  for  administering 


CLINIC  IN  PSYCHIATRY  39 

electrotherapeutic  treatment  whenever  this   particular  therapeusis   is 
indicated. 

4t       *       * 

The  Psychopathic  Hospital  affords  a  place  where  persons  may  be 
sent  for  short  observation  pending  opinion  as  to  the  necessity  of  com- 
mitting them  to  one  of  the  state  asylums,  or  as  to  whether  preliminary 
treatment  at  'this  institution  will  obviate  the  necessity  for  such  commit- 
ment. Thirty-eight  patients  have  already  been  registered  and  applica- 
tions for  a  number  of  others  are  under  consideration.  Thirty-two  of 
the  patients  were  transferred  from  the  state  asylums  at  the  opening  of 
the  hospital,  and  the  remainder  are  voluntary  patients  or  those  com- 
mitted as  private  and  county  charges.  In  addition  to  the  director  there  . 
is  constantly  in  attendance  the  resident  physician,  Doctor  George  Milton 
Kline.  Cases  are  continually  presenting  in  which  the  question  must 
be  determined  whether  the  condition  is  onp  of  neurasthenia  or  of  more 
serious  transitional  form  of  mental  disturbance,  and  physicians  through- 
out the  state  are  advised  that  patients  may  be  sent  to  the  institution 
according  to  three  processes. 

♦     *     * 

(i)  In  cases  where  application  shall  be  made  under  the  statute  to 
send  persons  claimed  to  be  insane  to  one  of  the  asylums  in  the  State 
of  Michigan,  the  Judge  of  Probate,  before  whom  said  application  is 
pending,  may  require  the  assistance  of  three  competent  and  skilled 
physicians  who  shall  investigate  the  condition  of  said  person  and  report 
the  same  to  the  Judge  of  Probate  in  writing  and  if  said  Judge  of  Pro- 
bate upon  investigation  ascertains  that  there  are  present  in  *the  con- 
dition of  the  patient  such  features  as  render  detention  in  a  psychopathic 
hospital  for  a  brief  period  advisable  as  a  precautionary  or  curative 
measure,  or  if  from  such  investigation  said  Judge  of  Probate  shall  be 
of  the  opinion  that  the  case  requires  the  services  or  treatment  of  special- 
ists in  the  treatment  of  diseases  other  than  those  of  the  nervous  system, 
he  shall  pass  an  order  directing  thaf  such  patient  shall  be  transported 
for  treatment  to  the  Psychopathic  Hospital  of  the  University  of  Michi- 
gan. If  the  patient  shall  continue  insane  after  any  such  special  treat- 
ment he  may  be  removed  to  and  confined  in  such  asylum  of  the  State 
of  Michigan  as  the  Probate  Judge  may  decree  in  his  order  of  committal 
to  the  Psychopathic  Hospital. 

4c       4t       4t 

(2)  In  case  the  Superintendent  of  either  of  the  asylums  for  the 
insane  shall  be  of  the  opinion  that  the  condition  of  mind  of  any  person 
confined  in  such  asylum  is  such  that  it  might  be  advisable  that  the 
patient  be  sent  to  the  Psychopathic  Hospital  he  shall  cause  such  person 
to  be  conveyed  thereto.  If  such  patient  shall  be  restored  to  sanity  while 
in  the  said  institution  he  shall  be  discharged,  but  in  case  such  patient 
shall  be  found  incurable,  the  Superintendent  of  the  University  Hospital 
shall  cause  said  person  to  be  returned  to  the  asylum  from  which  said 
person  was  received,  the  charges  for  the  care,  maintenance  and  trans- 


40  EDITORIAL  COMMENT. 

portation  to  be  paid  by  the  county  or  by  the  state,  depending  upon 
whether  the  patient  is  a  county  or  a  state  charge. 

♦       ♦       4k 

(3)  Persons  may  ccwnmit  themselves  as  voluntary  patients  under 
the  same  provisions  as  apply  to  such  commitments  to  the  state  asylums. 
The  exact  charge  for  maintenance  cannot  be  determined  at  this  time, 
but  will  depend  upon  the  average  per  capita  cost  for  maintaining  the 
hospital,  and  will  vary  with  the  number  of  patients  present  in  the  hospi- 
tal at  such  time.  It  will  be  somewhat  higher  than  for  the  care  of  patients 
in  the  state  asylums,  but  will  be  kept  as  low  as  is  consistent  with  proper 
treatment  and  the  purposes  for  which  the  Psychopathic  Hospital  was 
established.  It  will  probably  be  about  the  same  as  is  charged  in  the 
other  hospitals  of  the  University,  which  at  present  is  about  seven  dol- 
lars and  fifty  cents  per  week.  Private  patients  may  be  admitted  at  any 
time  under  any  of  the  foregoing  provisions.  In  such  cases  the  joint 
board  in  control  of  the  Psychopathic  Hospital  has  fixed  the  rate  of 
fifteen  dollars  per  week,  and  requires  the  friends  of  each  private  patient 
to  furnish  a  bond  in  the  penal  sum  of  one  thousand  dollars,  on  substan- 
tially the  same  conditions,  so  far  as  applicable,  as  those  required  by  the 
Michigan  asylums  for  the  insane.  There  shall  be  paid  by  such  private 
patient,  or  by  his  or  her  friends,  at  the  time  such  patient  is  admitted,  as 
an  advance  pa>Tnent  toward  the  support  of  such  patient,  the  sum  of 
fifty  dollars. 

ANNOTATIONS. 


THE  TREATMENT  OF  SARCOMA  WITH  MIXED  TOXINS. 
CoLEY,  in  a  contribution  to  the  recent  meeting  of  the  Southern  Sur- 
gical and  Gynecological  Association,  detailed  his  experience  with  a  mix- 
ture of  the  toxins  of  erysipelas  and  the  bacillus  prodigiosus  in  the  treat- 
ment of  sarcoma.  While  the  doctor  had,  until  recently,  employed  the 
mixture  only  in  such  cases  as  were  not  amenable  to  surgical  treatment, 
his  success  with  a  large  variety  of  cases  has  led  him  to  advocate  its 
administration  in  all  forms  of  the  disease  wherein  primary  surgical 
operations  have  been  performed.  Very  minute  doses  should  be 
employed  in  this  class  of  cases — only  large  enough  to  produce  slight 
reaction.  Before  inaugurating  radical  measures,  such  as  limb  amputa- 
tion, it  is  well  as  a  final  resort  to  employ  the  toxins,  since  in  a  number 
of  patients  disappearance  of  the  tumor  and  consequent  recovery  resulted 
from  their  administration.  In  arriving  at  his  conclusion  the  author 
observed  the  recovery  of  twelve  patients,  eight  of  whom  were  alive  and 
well  for  from  three  to  six  years  after  treatment.  Eight  of  the  above 
cases  were  of  the  round-cell  variety;  two  of  the  spindle-shape;  while 
the  tissue  of  the  remaining  two  patients  was  not  subjected  to  micro- 
scopic examination.  But  three  of  these  cases  were  personal.  How- 
ever, Coley  has  detailed  the  result  of  the  treatment  in  thirty-four  cases 
under   his   direct   supervision,   with   which   he  experienced   but  five 


TREATMENT  OF  MAL  DE  MER.  41 

reverses — recurrence  of  the  tumor  and  subsequent  death.  While  the 
demise  of  this  quintet  is  to  be  regretted,  it  would  seem  to  furnish  proof 
conclusive  of  the  correctness  of  the  diagnoses.  The  cases  under 
Coley's  personal  study,  and  those  which  he  has  been  able  to  observe  out- 
side his  own  practice,  embodied  (i)  round-celled,  (2)  mixed-celled,  (3) 
spindle-celled,  and  (4)  endothelioma. 


PEDAL  CHARACTERISTICS  OF  DIFFERENT  PEOPLES. 
Comparative  study  of  the  foot  in  barefoot  and  shoewearing  peoples 
is  detailed  by  Doctor  Hoffmann  in  a  late  issue  of  the  Quarterly  Bulletin 
of  the  Medical  Department  of  Washington  University,  The  relative 
length  of  the  foot  in  either  class  is  practically  the  same,  and  in  both 
classes  the  form,  function,  and  range  of  motion,  up  to  the  time  of  shoe 
adoption,  are  markedly  similar.  Deformation  and  inhibition  of  function 
follow  the  inauguration  of  shoewearing.  The  pedal  inheritance  of  the 
shoewearer's  progeny,  so  far  as  form  is  concerned,  is  synonymous  to 
the  heritage  acquired  by  the  offspring  of  barefoot  races,  the  natural 
symmetry,  however,  being  altered  after  encasement  in  modem  foot- 
wear. The  theory  is  advanced  that  the  strength  and  usefulness  of  the 
foot  is  not  dependent  on  the  height  and  shape  of  the  longitudinal  arch, 
and  breaking  and  lowering  of  the  arch  to  the  degree  of  flat-footedness  is 
rarely  resultant  from  weakness  at  this  point.  Moreover,  no  relation- 
ship exists  between  the  gait  and  the  height  of  the  arch. 


PHYSIOLOGIC  FUNCTION  OF  THE  PITUITARY  BODY. 
Anent  the  various  theories  that  have  been  expounded  regarding  the 
origin  of  sleep,  a  recent  contribution  by  Doctor  Alberto  Salmon,  to  the 
Italian  Medical  Congress,  is  of  vital  interest.  The  opinion  of  this 
scientist  is  that  an  internal  physiologic  secretion  from  the  pituitary 
gland  produces  somnolence.  He  further  expresses  the  idea  that  the 
bromine  contained  in  the  pituitary  structure  is  the  active  agent  in  sleep 
production,  and  cites  the  experience  of  the  profession  in  the  employ- 
ment of  the  glandular  extract  in  insomnia  to  substantiate  his  hypothesis. 
Somnolence  is  often  associated  with  certain  pathologic  conditions  of  the 
gland,  and  the  reverse  may  be  true,  since  in  many  cases  wherein  tumor 
is  present,  in  Graves'  disease,  in  cases  of  poisoning  with  consequent 
inhibition  of  the  secretion,  and  in  many  other  conditions,  including 
senility,  insomnia  is  the  prevailing  symptom.  While  sleeplessness  is 
said  to  result  from  an  insufficient  flow  of  the  pituitary  secretion,  an 
increase  of  the  fluid  by  the  ingestion  of  such  toxic  drugs  as  pilocarpine 
invariably  produces  a  condition  of  profound  sleep. 


THE  MECHANICAL  TREATMENT  OF  MAL  DE  MER. 

A  MECHANICAL  dcvicc  lately  invented  by  Doctor  Carl  Brendel,  a 
Russian  physician,  promises  relief  from  seasickness  to  individuals  not 
proficient  in  nautical  accomplishments.  While  the  condition  has  been 
combatted  more  or  less  successfully  by  the  administration  of  drugs  and 


42  EDITORIAL  COMMENT. 

chemicals,  not  many  remedies  of  a  mechanical  nature  have  been  offered 
to  the  maritime  traveler,  and  hence  announcement  of  the  latest  preven- 
tive will  be  accorded  consideration.  The  novelty  is  in  the  form  of  a 
chair,  the  seat,  arms,  legs,  and  back  of  which  are  freely  movable.  The 
idea  of  the  designer  is  that  a  counteraction  of  the  long  pitching  move- 
ment of  the  sea-going  vessel,  by  the  short  up  and  down  and  occasional 
backward  movement  of  the  chair — the  motive  power  of  which  is  fur- 
nished by  a  small  electric  motor — tends  to  overcome  the  seasickness. 
The  inventor  does-  not  claim  for  his  chair  immunizing  properties,  nor 
does  he  even  venture  that  it  will  effect  permanent  cure,  but  those  who 
have  had  opportunity  to  test  its  virtues  declare  that  a  few  moments  of 
repose  in  the  chair  offer  relief  from  the  unpleasant  symptoms. 


CONTEMPORARY. 


PHYSICIANS  AND  PHILOSOPHERS. 

[professor  CHARLES  WILLIAM  SUPSR,  OP  OHIO  UNtVRRSITT,  IN  POPULAR  SCIENCE  MONTHLY.] 

Although  the  initial  assonance  of  physician  with  philosopher 
is  purely  accidental,  it  is  nevertheless  a  fact  that  philosophy  and  the 
healing  art  or  medical  science  have  been  closely  associated  with  each 
other  from  their  earliest  beginnings.  It  cannot  but  be  regarded  as  a 
singular  coincidence  that  for  two  and  a  half  millenniums  physic  and 
philosophy,  the  practitioners  of  the  healing  art  and  the  real  or  professed 
lovers  of  knowledge,  have  been  more  or  less  intimate  friends.  At  the 
beginning  they  seem  to  have  found  themselves  in  each  other's  company 
almost  by  chance;  then  by  a  sort  of  elective  affinity  like  that  which 
often  springs  up  between  persons  of  opposite  sex  whose  paths  in  the 
ordinary  course  of  events  incidentally  crossed  each  other,  to  have 
discovered  that  they  could  make  the  rest  of  the  journey  together  to 
reciprocal  advantage. 

Herodotus,  the  Father  of  History,  was  a  native  of  Halicarnassus, 
and  Hippocrates,  the  Father  of  Medicine,  his  younger  contemporary, 
first  saw  the  light  on  the  island  of  Kos,  only  a  few  leagues  distant. 
Born  in  the  same  year  with  Hippocrates  was  the  philosopher  Diogenes, 
of  Apollonia  in  Crete,  whose  few  literary  remains  not  only  attest  his 
interest  in  human  anatomy,  but  also  furnish  proof  that  he  early  came 
under  the  influence  of  the  Ionian  thinkers.  Though  never  regarded 
as  a  physician,  but  only  as  a  philosopher,  he  tells  us  in  one  of  the  very 
brief  fragments  that  have  been  preserved  that  the  veins  of  the  human 
body  are  divided  into  two  branches ;  that  they  pass  through  the  abdom-  ' 
inal  cavity  along  the  backbone,  one  on  the  right  side,  the  other  on  the 
left,  into  the  legs  y  and  that  two  branches  pass  into  the  head.  He  then 
goes  on  to  describe  the  course  of  the  blood-vessels  and  their  ramifica- 
tions as  far  as  the  ends  of  the  toes,  the  fingers,  and  so  on.  It  may 
safely  be  assumed  from  this  fragment  that  Diogenes  gave  much  atten- 
tion to  the  structure  of  the  human  body. 


PHYSICIANS   AND  PHILOSOPHERS.  43 

In  the  southwestern  portion  of  Asia  Minor,  the  disciples  of 
Asclepias  or  iEsculapius  had  several  therapeutic  establishments,  and 
it  is  in  connection  with  these  that  we  discover  the  first  signs  of  what 
may  be  called  the  healing  art  in  the  entire  ancient  world. 

It  was  especially  the  priests  of  the  temples  of  Kos  and  Knidos  who 
cultivated  a  primitive  and  simple  medical  science  in  connection  ynth 
their  service  of  the  god.  In  this  part  of  Asia,  also,  philosophy  took 
its  rise.  For  not  only  was  Hippocrates  a  philosopher  as  well  as  a 
physician,  but  the  same  affirmation  can  be  made  of  a  considerable 
number  of  Greek  thinkers.  Diogenes  has  just  been  mentioned.  More- 
over the  two  lines  of  investigation  were  often  parallel  in  other  parts 
of  the  ancient  world.  Empedocles  who  was  a  full  generation  older 
is  supposed  to  have  been  a  physician.  Pythagoras,  who  lived  still 
earlier,  though  perhaps  not  a  physician  in  the  strict  sense  of  the  word, 
gave,  according  to  tradition,  no  little  attention  to  the  laws  of  health 
and  formulaited  a  mmiber  of  precepts  supposed  to  be  conducive  to  its 
preservation.  Plato,  though  not  a  special  student  of  the  healing  art, 
shows  in  many  passages  of  his  Dialogues,  a  considerable  degree  of 
familiarity  with  the  subject.  Aristotle  was  the  son  of  a  physician  and 
was  indebted  to  his  father  not  only  for  much  of  his  knowledge,  but 
also  for  his  interest  in  natural  history;  while  his  pupil  Theophrastus 
is  regarded  as  the  father  of  medical  botany.  Among  the  Romans  we 
find  Pliny  paying  a  good  deal  of  attention  to  facts  or  supposed  facts 
in  the  realm  of  medicine.  The  same  thing  is  true  of  Seneca  and  still 
more  of  Vitruvius,  though  it  would  perhaps  be  as  far  astray  to  call 
him  a  philosopher  as  a  physician  in  the  strict  significance  of  the  terms. 
Toward  the  latter  part  of  the  second  century  we  are  carried  back  again 
to  Asia  Minor  to  find  in  Galen  of  Pergamus,  not  only  a  distinguished 
writer  on  philosophical  subjects,  but  a  man  whose  reputation  as  a 
physician  is  fully  equal  to,  if  not  greater  than,  that  of  Hippocrates, 
notwithstanding  that  he  was  a  man  of  less  native  capacity.  It  may 
be  confidently  affirmed  that  Hippocrates,  Celsus  and  Galen  represent 
the  entire  healing  art  until  modern  times.  With  respect  to  Cornelius 
Celsus,  who  lived  in  the  reign  of  Tiberius  and  who  occupies  an  impor- 
tant place  in  the  history  of  ancient  medicine,  it  mu.«t  be  said  that  it 
is  uncertain  whether  he  was  really  a  physician.  It  is  rather  more 
than  probable  that  he  was  a  savant.  On  the  other  hand,  the  question 
is  raised.  Why  would  any  one  but  a  practical  physician  compile  a 
medical  work?  Could  any  other  person  do  it  successfully?  Another 
singular  fact  that  has  added  to  the  difficulty  of  defining  Celsus'  posi- 
tion is  that  even  as  late  as  the  age  in  which  he  lived  nearly  all  the 
physicians  in  Rome  were  Greek  freedmen.  At  any  rate  the  work  of 
Celsus  at  once  sprang  into  prominence,  and  though  it  is  only  part  of 
an  encyclopedic  compilation,  nothing  else  remains  at  the  present  day. 
As*is  the  case  with  not  a  few  other  works  of  antiquity,  its  connection 
with  modem  times  hangs  by  the  slender  thread  of  a  singfle  manuscrpit 
from  which  all  later  copies  have  been  made.  This  portion  of  the 
encyclopedia  of  Celsus  has  also  an  important  historical  value  since  it 


44  ^  MEDICAL  NEWS. 

gives  brief  sketches  of  more  than  seventy  physicians  who  had  lived 
before  his  time  and  had  attained  a  certain  degree  of  eminence.  It 
had  not  escaped  his  observation  that  only  persons  of  mediocre  ability 
are  loth  to  admit  errors,  while  the  reverse  is  true  of  genius,  since  there 
still  remains  a  large  residuum  of  truth  in  its  possession. 

[TO  BE  CONTINUED.] 


MEDICAL  NEWS. 


A  PHYSICIAN  GRANTED  PATRONYMIC  APPELLATION. 

Doctor  Charles  Beylard  Nancrede,  Professor  of  Surgery  in  the 
University  of  Michigan,  recently  petitioned  the  Probate  Court  of  the 
County  of  Washtenav^^  for  a  change  of  his  name,  and  he  will  hence- 
forth bear  the  appellation  of  "Charles  Beylard  Guerard  de  Nancrede." 
The  application  recounts  the  information  that  the  grandfather  of  the 
petitioner  bore  the  cognomen  of  "Paul  Joseph  Guerard  de  Nancrede," 
but  discarded  the  "de"  at  the  time  of  his  naturalization  as  an  American 
citizen;  that  the  father,  who  was  bom  in  1799,  was  baptised  "Thomas 
Dixey"  and  never  utilized  the  family  patronymic  "Guerard  de  Nan- 
crede," simply  abridging  the  name  to  "Nancrede."  Restoration  of  the 
name  to  its  original  form  was  desired  for  family  reasons. 


THE  DEMISE  OF  DE  WECKER. 

Baron  De  Wecker,  of  Paris,  who  died  recently,  was  seventy-three 
years  of  age.  Through  his  death  the  world  has  lost  one  of  the  "Fathers 
of  Ophthalmology"  and  one  of  the  greatest  ophthalmic  surgeons  of 
his  day.  .He  was  oculist  to  Napoleon  III,  and  to  the  Spanish  Court, 
and  was  also  von  Graefe's  chief  of  clinic  and  associate  of  Artt  and 
Jaeger.  He  succeeded  Desmarres  in  Paris  and  introduced  the  ophthal- 
moscope in  France.  The  French  government  made  him  Grand  Officer 
of  the  Legion  of  Honor,  and  he  received  decorations  from  nearly  every 
crowned  head  of  Europe, 


MINOR  INTELLIGENCE. 

Our  printing  house  is  recovering  from  the  effects  of  the  recent 
printers'  strike  and  succeeding  numbers  of  this  journal  will  be  issued 
promptly. 

The  Hungarian  government  has  awarded  one  thousand  kronen 
to  Professor  Kohut,  of  Konigsburg,  for  his  prize  essay  on  the  treat- 
ment of  trachoma. 

According  to  report  the  original  copy  of  Harvey's  paper  on  the 
"Circulation  of  the  Blood"  was  sold  recently  for  £30.  The  manuspript 
was  written  in  1628. 


MINOR  INTELLIGENCE.  45 

The  Western  Penitentiary  of  Pennsylvania  is  threatened  with  an 
q)idemic  of  smallpox.  A  prisoner  who  has  been  incarcerated  for  over 
a  year  has  mysteriously  contracted  the  disease,  and  every  precaution  is 
being  exerted  to  protect  the  nine  hundred  fifty  inmates  of  the  prison. 

The  government  contemplates  the  erection  of  a  $400,000  hospital 
for  the  Army  and  Navy.  Doctor  Louis  de  Clermont,  of  Washington, 
has  secured  a  site  of  over  six  hundred  acres  of  ground  in  Illinois,  and 
a  structure  sufficiently  large  to  accommodate  three  thousand  patients 
mil  be  erected  thereon. 

Minnesota  has  a  law  compelling  physicians  to  report  to  the 
register  of  deeds  of  their  county,  all  accidents  in  which  the  victim  is 
disabled  for  a  period  of  two  weeks  or  longer.  Failure  to  comply  with 
the  enactment  is  punishable  by  a  fine  of  one  hundred  dollars  or  impris- 
onment for  a  period  of  six  months. 

An  interesting  case  of  premature  maternity  is  reported  from 
Bristol,  Tennessee.  The  mother  is  a  colored  girl,  ten  years  of  age,  a 
native  of  Virginia,  and  the  infant  weighs  eight  pounds.  It  is  said 
that  chances  for  its  survival  are  excellent  and  that  the  mother  has 
experienced  a  complete  recovery  from  the  early  parturition. 

Spring  Beach,  a  suburb  of  Seattle,  Washington,  is  to  have  a  new 
$30,000  sanatorium.  A  four-story  structure  is  contemplated,  and  as 
the  promoters  have  already  secured  one  hundred  acres  of  land,  ample 
grounds  are  assured.  The  institution  will  afford  accommodation  to 
five  hundred  patients,  and  will  be  under  the  supervision  of  a  staff  of 
fifteen  physicians. 

Brooklyn  has  a  novel  institution  in  the  form  of  a  public  library  for 
the  blind.  Inasmuch  as  raised  letter  books  are  quite  expensive,  and  as 
few  blind  persons  can  afford  indulgence  in  them,  the  library  is  a  very 
welcome  acquisition  to  the  educational  system  of  the  city.  Most  of  the 
volumes  deal  with  nature  or  light  emotional  subjects,  as  sightless  indi- 
viduals prefer  this  variety  to  works  of  more  profound  type. 

The  war  department  has  provided  for  the  establishment  of  a  chair 
of  military  hygiene  at  the  West  Point  Military  Academy.  The  cadets 
will  receive  sufficient  medical  knowledge  to  enable  them  to  care  for 
troops  from  a  hygienic  standpoint,  and  to  administer  relief  in  superficial 
injuries.  The  founding  of  the  chair  was  doubtless  prompted  by  the 
remarkable  results  obtained  by  Japanese  military  surgeons  in  the  late 
war. 

The  German  Rontgen  Society  has  issued  an  inaugural  volume  of 
proceedings,  detailing  the  work  of  the  first  congress  of  .r-ray  workers. 
The  book  is  divided  into  five  parts  enumerating  the  various  features 
of  the  meeting.  The  first  section  is  merely  a  compilation  of  the  physi- 
cians who  were  in  attendance;  section  two  is  devoted  to  exhibits; 
section  three  contains  the  papers  read  and  the  discussions  thereon; 
and  sections  four  and  five  are  devoted  to  a  history  of  the  organization, 
and  the  publication  of  communications. 


46  MEDICAL  NEWS. 

Professor  Terriani  estimates  that  eighty  per  cent  of  the  child 
criminals  of  Italy  owe  their  vicious  instincts  to  unsuitable  environment 
and  insufficient  educational  advantages.  He  further  states  that  thirty 
per  cent  of  the  criminals  of  the  kingdwn  have  not  yet  reached  legal  age, 
and  that  of  this  number  eighty-five  per  cent  are  thieves. 

Efforts  are  being  exerted  toward  the  establishment  of  a  medical 
college  for  the  United  Provinces  of  India,  as  a  memorial  of  the  visit  of 
the  Prince  and  Princess  of  Wales  to  the  Peninsular.  The  question  has 
long  been  agitated  and  it  is  probable  that  matters  have  at  last  reached 
a  focus,  as  each  province  is  endeavoring  to  outdo  the  other  in  the  matter 
of  support. 

The  consolidation  of  the  Medical  and  Surgical  Monitor  and  the 
Centred  States  Medical  Magazine  has  been  effected  at  Indianapolis, 
the  new  publication  being  known  as  the  Central  States  Medical 
Monitor,  Doctors  S.  E.  Earp  and  S.  P.  Scherer  will  comprise  the 
editorial  staff.  The  Monitor  is  the  latest  acquisition  to  the  field  of 
independent  medical  journalism,  and  we  wish  it  success. 

The  National  Association  for  the  Study  of  Epilepsy  has  announced 
its  intention  to  award  a  prize  of  $300  for  the  best  original  paper  on  the 
"Etiolc^  of  Epilepsy."  Essays  must  be  submitted  for  approval  before 
September  i,  1906,  as  the  prize  essayist  will  be  announced  in  November. 
Physicians  desiring  information  regarding  the  award  may  communicate 
witii  the  president  of  the  association,  Doctor  W.  P.  Spratling,  of  Sonyca, 
New  York. 

The  twenty-ninth  annual  meeting  of  the  American  Dermatological 
Association  was  held  in  New  York  City  on  December  28,  29  and  30, 
1905.  The  following  officers  were  elected  for  the  ensuing  year:  Presi- 
dent, Doctor  Milton  B.  Hartzell,  of  Philadelphia;  vice-president, 
Doctor  T.  Caspar  Gilchrist,  of  Baltimore;  secretary-treasurer,  Doctor 
Grover  W.  Wende,  of  Buffalo.  Cleveland  was  designated  as  the  meet- 
ing place  foV  1906. 

In  accordance  with  an  order  from  the  Commissioner  of  Immigration 
of  the  port  of  New  York,  saloon  and  second  cabin  passengers  will 
henceforth  be  subjected  to  examination  by  the  government  physicians. 
Heretofore  the  order  affected  only  steerage  passengers,  but  owing  to 
rejected  immigrants  taking  advantage  of  legal  inadequacy  by  returning 
as  saloon  passengers  the  regulations  in  regard  to  such  persons  were 
made  more  stringent. 

Boston  has  a  new  hospital  for  the  treatment  of  diseased  horses, 
dogs,  cats,  and  other  domestic  animals.  The  institution  is  to  be 
equipped  in  the  most  approved  fashion — operating  rooms,  exercising 
paddocks,  private  wards,  and  baths  being  stipulated  in  the  architect's 
plans.  A  free  clinic  will  be  conducted  weekly  for  animals  belonging 
to  the  poorer  classes.  The  hospital  is  under  the  direction  of  Samuel 
F.  Wadswords,  M.  D.  V.,  a  graduate  of  the  Harvard  Veterinary 
School. 


INTERNATIONAL  CLINIC.  47 

Paul  Revere,  the  Revolutionary  patriot,  according  to  the  follow- 
ing announcement  taken  from  an  old  copy  of  the  Boston  Gazette  and 
Country  Journal,  must  have  been  a  dentist :  "Whereas,  many  persons 
are  so  unfortunate  as  to  lose  their  Fore-teeth  by  Accident  and  other- 
ways,  to  their  great  Detriment,  not  only  in  Looks,  but  speaking  both 
in  Public  and  Private : — This  is  to  inform  all  such  that  they  may  have 
them  replaced  with  artificial  ones,  that  looks  as  well  as  the  Natural  & 
answers  the  end  of  Speaking  to  all  Intents,  by  Paul  Revere,  Goldsmitji, 
near  the  head  of  Dr.  Clarke's  Wharf,  Boston.  All  Persons  who  have 
had  false  Teeth  fixt  by  Mr.  John  Baker,  Surgeon  Dentist,  and  they 
have  got  loose  (as  they  will  in  time),  may  have  them  fastened  by  the 
above  who  learnt  the  Method  of  fixing  them  from  Mr.  Baker." 


RECENT  LITERATURE. 


REVIEWS. 

COAKLEY'S  LARYNGOLOGY.* 

The  popularity  of  the  two  preceding  editions  is  suflScient  proof  of 
the  value  of  this  work.  In  its  third  edition  it  has  been  revised,  enlarged 
and  brought  completely  up-to-date.  Due  to  its  completeness  and  to 
its  ccMnpact  form  it  serves  equally  well  as  a  text-book  for  students  and  as 
a  reference  book  for  practitioners  and  specialists.  The  most  important 
revision  in  this  last  edition  is  that  of  the  chapter  on  the  "Diseases  of  the 
Accessory  Sinuses."  This  has  been  entirely  rewritten  and  gives  very 
clearly  the  author's  standpoint  upon  this  very  important  division  of 
the  specialty. 

Throughout  the  work  is  well  written  and  well  illustrated  and  offers 
a  consistent  and  satisfactory  exposition  of  its  subject  matter. 

*A  Manual  of  Diseases  of  the  Nose  and  Throat.  By  Cornelius  G. 
Coakley,  A.  M.,  M.  D.,  Professor  of  Laryngology  in  the  University  and 
Bellevue  Hospital  Medical  College ;  Laryngologist  to  Columbus  Hospi- 
tal, et  cetera,  New  York.  New  (third)  edition,  revised  and  enlarged. 
In  one  i2mo.  volume  of  594  pages,  with  118  engravings  and  five  colored 
plates.  Qoth  $2.75  net.  Lea  Brothers  &  Company,  Publishers,  Phila- 
delphia and  New  York,  1905.  -  R.  b.  c. 


INTERNATIONAL  CLINICS.* 
The  latest  volume  of  this  well-known  series  gives  us  as  usual  a  valu- 
able collection  of  sound  practical  papers,  with  a  few  theoretic  or  sugges- 
tive ones.  Among  the  former  may  be  mentioned  a  very  useful  article  on 
"Radiothcirapy,"  by  George  C.  Johnston;  one  on  the  "Symptomatic 
Treatment  of  Tuberculosis,"  b);  Noble  P.  Barnes ;  "Membranous  Colic," 
by  Alexander  McPhedran ;  "Addison's  Disease,"  by  Edward  F.  Wells ; 
"Cancer  of  the  Bile-Duct,"  by  F.  Parkes  Weber  and  E.  Michel ;  "Frac- 


48  RECENT  LITERATURE. 

ture  of  the  Patella,"  by  J.  Sherman  Wainwright ;  "Ethyl  Chlorid  Anes- 
thesia," by  Thomas  D.  Luke.  Richard  Kretz  gives  a  succinct  account 
of  "Cirrhosis  of  the  Liver,"  in  its  anatomic  relations.  The  articles  of 
Albert  Robin,  on  the  "Action  of  Metallic  Ferments  on  Metabolism  and 
Pneumonia,"  and  Professor  Teissier  on  "Opotherapy  in  Renal  Insuffi- 
ciency," are  interesting.  Sanger  Brown  has  a  thoughtful  article  on  the 
"Early  Stages  of  Acute  Poliomyelitis,"  so  often  overlooked  in  practice, 
and  there  are  others  in  Ophthalmology  and  Rhinology.  John  W.  Wain- 
wright's  article  on  "Serum  Therapy"  is  brief  to  the  danger  point.  If 
vaccination  is  to  be  includedin  such  an  article  it  would  seem  worth 
while  to  give  some  explanation  of  unusual  views  that  appear,  such  as 
the  one  that  "true  animal  vaccine"  and  "variola  vaccine"  are  different, 
or  are  distinguished  in  practice,  or  that  "pulp  consists  of  proliferated 
epithelium." 

On  the  whole  the  volume  is  not  quite  up  to  the  standard  of  some  of 
its  predecessors,  but  well  deserves  the  continued  popularity  acquired  by 
the  series.  G.  d. 

*A  Quarterly  of  Illustrated  Clinical  Lectures  and  Especially  Pre- 
pared Original  Articles,  et  cetera.  Edited  by  A.  O.  J.  Kelly,  A.  M., 
M.  D.,  Philadelphia.  Volume  III.  Fifteenth  Series,  1905.  J.  B.  Lip- 
pincott  Company. 

HAREMS  TEXT-BOOK  OF  PRACTICAL  THERAPEUTICS.* 

The  eleventh  edition  of  this  work,  enlarged,  revised  and  largely 
rewritten  is  before  the  profession.  Among  the  changes  that  have  been 
made  in  bringing  out  this  edition  the  changing  of  the  doses  of  drugs  to 
conform  to  the  new  Pharmacopeia  is  the  most  important.  To  the  physi- 
cian this  is  a  labor-saving  provision,  to  the  patient  a  guarantee  that  his 
medicines  are  efficient  and  safe,  and  to  the  student  a  path  that  leads  m 
the  way  he  should  go. 

The  volume  contains  two  sections,  one  dealing  with  drugs,  remedial 
measures  and  foods,  the  other  with  the  use  of  drugs,  in  treating  disease. 
The  book  has  the  good  points  of  its  predecessors  and  several  other 
good  points  in  addition. 

Hare's  Therapeutics  has  come  to  take  on  some  of  the  characteristics 
of  a  government  report.  A  new  edition  is  looked  for  yearly  and  the 
opinions  and  the  conclusions  expressed  are  viewed  as  coming  from  one 
in  authority.  D.  L.  p. 

*A  Text-Book  of  Practical  Therapeutics,  with  Especial  Reference 
to  the  Application  of  Remedisil  Measures  to  Disease  and  their  Employ- 
ment upon  a  Rational  Basis.  By  Hobart  Amory  Hare,  M.  D.,  B.  Sc, 
Professor  of  Therapeutics  and  Materia  Medica  in  the  Jefferson  Medical 
College  of  Philadelphia,  Physician  to  the  Jefferson  Hospital,  et  cetera. 
New  eleventh  edition,  enlarged  and  thoroughly  revised  to  accord  with 
the  eighth  decennial  revision  of  the  United  States  Pharmacopeia,  1905. 
In  one  octavo  volume  of  910  pages,  with  113  engravings  and  four 
colored  plates.  Qoth,  $4.00,  net;  leather,  $5.00,  net;  half  morocco, 
$550,  net.     Lea  Brothers  &  Company,  Philadelphia  and  New  York. 


MOSKS    GLNN. 


A  PROFESSIONAL  MEDICAL  JOURNAL. 


VOLUME  XXVIII.  FEBRUARY.  1906.  .  NUMBER  II. 


ORIGINAL  ARTICLES. 


MEMOIRS. 


THE  LIFE  AND  CHARACTER  OF  MOSES  GUNN. 

A.  M.,  M.  D.,  LL.  D.* 

By  C.  B.  G.  de  NANCR^DE,  A.  M.,  M.  D.,  LL.D.,  Ann  Arbor,  Michigan. 

PROnSSOIt  OF  SUKGERT  AND  CUNICAL  SUKGBXT,  AND  DIKBCTOR  OF  TMB  SURGICAL  CLINICS,  IN 
THB  UNIVSRSmr  OF  MICHIGAN. 

Mr.  President,  Members  of  the  Faculty,  Students  of  the  Department  of 
Medicine  and  Surgery,  Ladies  and  Gentlemen: 

While  perhaps  it  is  appropriate  that  to  the  present  incumbent  of  the 
Chair  of  Surgery  has  been  deputed  the  task  of  presenting  to  you  a  few 
of  the  salient  facts  in  the  life  and  character  of  the  first  Professor  of  Sur- 
gery in  this  institution,  I  cannot  but  feel  that  it  is  most  unfortunate  that 
one  so  little  associated  with  him  personally,  had  to  be  selected.  This 
man,  to  whom  the  medical  school  owes  so  much,  who  in  every  sense  of 
the  word  was  one  of  our  Founders,  can  hardly  have  justice  done  him  by 
one  who  never  worked  with  him  in  those  early  days  when,  as  he  taught 
others,  he  learned  himself,  day  by  day,  how  the  facts  of  medical  science 
could  best  be  conveyed ;  for,  as  you  will  see,  he  was  practically  without 
training  as  a  teacher  when  at  one  bound  he  was  called  upon  to  fill  two 
of  the  most  important  chairs  in  the  Medical  Department  of  the  Univer- 
sity of  Michigan,  and  that  too,  in  a  school  depending  entirely  for  its 
future  success  upon  the  ability  of  its  untried  faculty.  How  well  he 
succeeded,  it  Will  be  my  endeavor  to  show  you,  and  to  point  out  those 
qualities  by  means  of  which  this  success  was  achieved. 

The  subject  of  our  memoir  was  born  in  East  Bloomfield,  New  York, 
the  youngest  of  the  four  children  of  Linus  Gunn  and  Esther  Brunson. 
His  parents  were  of  Scotch  ancestry,  Moses  taking  after  his  father 
physically,  the  latter  being  a  tall  and  powerful  man.    Like  other  men 

♦An  Address  delivered  before  the  Faculty  and  Students  of  the  Medical  Department 
of  the  University  of  Michigan,  on  "Founders'  Day,"  February  22,  1906. 


50  ORIGINAL  ARTICLED. 

who  have  achieved  eminence,  as  a  child  Doctor  Gunn  showed  some  of 
those  traits  of  character  which  explain  in  a  great  measure  his  success, 
especially  his  love  of  mechanics,  and  a  distinctly  quick  and  logical  miad 
that  swne  anecdotes  which  I  shall  relate  will  prove. 

The  family  homestead  being  located  on  the  main  stage  route  from 
Rochester  to  Canandaigua  was  so  conveniently  situated  that,  encouraged 
by  the  reputation  the  Gunns  had  for  hospitality,  travelers  often  stopped 
there,  and  clergymen  and  other  men  of  education  made  short  stays  with 
them.  Doubtless,  the  wits  of  the  young  Moses  were  sharpened  and 
stimulated  by  frequently  listening  to  the  conversation  of  educated  and 
cultured  men,  this  in  some  measure  accounting  for  his  nimbly-acting 
mind.  One  day,  when  only  a  little  fellow,  he  was  tinkering  at  a  home- 
made vehicle,  and  a  brother  teasingly  asked  him  why  he  did  not  hitch 
up  the  old  dog  and  make  him  pull  the  wagon.  Moses  replied  that  he 
was  too  old.  The  brother  retorted  *'I  am  going  to  kill  this  dog,  for  he 
is  too  old  and  useless,  and'-^^^t^  ujilgo^tw^h  room,"  when  instantly 
Moses  flashed  back,  "iMg^are  going  to  Kill^exery thing  that  is  too  old, 
you  had  better  go  in  amlp  kill  your  grandmotK 

Again,  dissatisfiecft  witWDfiiT  8^€l9ft7^skedi  why  he  had  been  so 
called,  and  being  told  B^^is  mother  that  it  wWthe  name  of  his  grand- 
father, who  was  a  courte8^g/g^mjsybl«  p}<^j;gatieman,  whom  his  parents 
hoped  to  have  him  emulate,  hetlUiLRljf  aiTswered,  "that  is  a  good  reason 
but  I  could  just  as  well  have  emulated  him  without  his  name."  When 
barely  five,  one  Thanksgiving  day  he  was  overlooked  when  some  deli- 
cacy was  handed  around.  Turning  to  his  aunt  he  reproachfully  said, 
"Whatevr  that  uhis  you  didn't  pass  it  to  me/'  At  once  the  dish  was 
handed  him  when  with  sly  humor  he  said,  "Oh,  never  mind,  I  do  not 
twint  it,  only  I  like  to  have  folks  pass  me  things  when  I  am  around." 

Like  straws  which  prove  which  way  the  wind  blows,  these  anecdotes 
show  that  the  quickness  of  perception,  power  of  logical  deduction,  and 
sense  of  humor  which  characterized  his  after  life,  even  at  this  early  age, 
were  unusually  developed. 

I  would  especially  ask  for  the  attention  of  the  undergraduate  stu- 
dents to  the  brief  remarks  I  shall  make  concerning  Doctor  Gunn's  boy- 
hood. Although  for  a  time,  as  will  be  seen,  seriously  handicapped  by 
ill-health,  enjoying  no  special  advantages  over  his  fellows,  yet,  availing 
himself  of  every  opportunity,  however  unpromising  it  appeared,  he 
actually  converted  what  would  have  been  obstacles  to  others,  into  oppor- 
tunities for  planting  his  feet  on  the  lowest  rungs  of  the  ladder  of 
success.     As  Longfellow  says: 

"All  common  things,  each  day's  events. 
That  with  the  hour  begin  and  end. 
Our  pleasures  and  our  discontents, 
Are  rounds  by  which  we  may  ascend. 

We  have  not  wings,  we  cannot  soar; 

But  we  have  feet  to  scale  and  climb 
By  slow  degrees,  by  more  and  more, 

The  cloudy  summits  of  our  time." 


LIFE  OF  MOSES  GUNN.  51 

Sent  early  to  school,  from  twelve  to  fifteen  years  of  age  he  had  for 
his  tutor  a  young  theological  student,  a  resident  in  his  father's  house. 
Finally,  entering  the  Bloomfield  Academy  he  continued  his  studies 
there  until  attacked  by  a  serious  illness,  his  behavior  during  which 
showing  how  his  strong  will  could  compel  his  suffering  body  at  any 
cost  to  obey  that  which  approved  itself  to  him  as  right.  Thus,  during 
part  of  this  illness  he  rode  to  school,  at  times  suffering  so  much  that 
he  could  only  permit  his  horse  to  walk,  while  the  pain  in  his  side  made 
it  almost  impossible  for  him  to  sit  upright  in  the  saddle,  but,  recog- 
nizing the  evils  of  such  an  attitude  in  the  young,  he  sternly  resisted  the 
inclination. 

Undismayed  by  his  illness  he  displayed  much  fortitude.  Instead  of 
succitmbing  and  abandoning  the  hope  of  completing  his  education,  he 
accomplished  what  he  could  and  devoted  himself  to  the  recovery  of  his 
health.  The  execution  of  this  project  requiring  extreme  care  for  two 
years  and  finally  a  change  of  residence  and  a  sea  voyage,  shows  the 
mental  fibre  possessed  by  this  youth,  and  the  discipline  of  patience 
required  must  have  served  to  mould  his  character  with  finer  lines  and 
into  more  compact  form. 

A  few  months  after  his  return  from  his  voyage  he  commenced  the 
study  of  medicine  under  Doctor  Edson  Carr,  of  Canandaigua.  That 
the  same  keenness  of  observation,  and  accurate  correlation  of  the  facts 
thus  obtained  were  as  prominent  traits  of  character  during  his  student 
days  as  they  had  been  in  his  childhood  is  proved  by  a  remark  of  Doctor 
Carr  evidencing  the  opinion  this  shrewd  observer  had  early  formed  of 
Gunn.  Walking  side  by  side  one  day,  the  wind  blew  a  corner  of  the 
doctor's  cloak  over  Gunn's  arm,  when  the  pupil  remarked,  "How  proud 
I  should  be  if  your  mantle  could  fall  upon  my  shoulders."  Gazing 
keenly  at  him  for  a  moment  Doctor  Carr  replied,  "My  boy,  you  will 
wear  a  greater  mantle  than  mine."  Doctor  Carr  enjoyed  a  high  repu- 
tation as  an  operator  and  was  greatly  admired  by  his  pupil,  yet  on  one 
occasion  after  assisting  his  preceptor  in  the  performance  of  an 
operation,  Gunn  remarked  to  a  friend  that  if  he  ever  met  with  a  similar 
case  he  would  treat  it  after  a  radically  different  method.  Years  after, 
in  a  number  t>f  instances,  the  truth  of  his  youthful  previsions  was  jus- 
tified by  his  results.  Such  independence  of  judgment  coupled  with  a 
well-balanced  mind  such  as  Gunn  possessed,  was  one  of  the  chief 
reasons  for  his  early  success ;  when  sure  he  was  right,  he  did  not  hesi- 
tate to  contravene  professional  conventions. 

A  former  student  of  Doctor  Carr's,  our  own  Corydon  L.  Ford,  then 
Demonstrator  of  Anatomy  in  Geneva  Medical  College,  on  his  occasional 
visits  to  his  old  preceptor  was  struck  by  Gunn's  "earnestness  in  what- 
ever he  undertook,"  and  especially  "his  enthusiastic  devotion  to  the 
study  of  anatomy."  Upon  the  observations  thus  casually  made  by  Ford 
depended  the  after  life  of  young  Gunn.  I  am  anxious  in  thus  selecting 
from  the  mass  of  material  at  my  disposal  the  really  epoch-making 
events  of  Doctor  Gunn's  life,  that  students  may  recognize  how  at  an/ 
period  of  life  a  man  as  he  really  is,  not  as  he  wishes  to  appear,  is  often 


62  ORIGINAL   ARTICLES. 

subjected  to  an  unsuspected  scrutiny  upon  the  results  of  which,  all 
unknowingly  to  himself,  his  future  in  great  measure  may  depend. 

In  October,  1844,  entering  the  Geneva  Medical  College,  Gunn  was 
at  once  conceded  to  be  a  man  of  unusual  promise,  and  Dr.  Ford's 
originally  high  opinion  was  so  justified  that,  when  the  latter's  health 
prevented  him  from  conducting  his  work  in  practical  anatomy,  he 
entrusted  to  the  young  undergraduate  the  instruction  of  his  classmates, 
thus  giving  the  opportunity  Gunn  needed.  Ford  afterwards  ^aid  that 
Gunn  in  performance  of  these  duties  evinced  so  much  aptness  and  skill 
in  instructing  others,  that  his  future  success  as  a  teacher  and  operator 
were  clearly  foreshadowed.  Even  at  this  time  young  Gunn,  encouraged 
by  Ford,  and  given  a  chance  to  show  his  capacity  as  a  teacher,  when 
talking  over  the  future,  indulged  the  hope  that  he  and  Ford  might  at 
no  distant  time  be  associated  in  a  medical  school,  Ford  as  the  Anatomist, 
Gunn  as  the  Surgeon.  To  paraphrase  the  Shakespearean  saying,  the 
wish  became  the  father  to  the  thought,  and  the  thought  induced  Gunn 
to  bend  all  his  energies  to  translate  his  thought  into  a  reality. 

The  quickness  with  which  Gunn  availed  himself  of  an  opportunity, 
which  most  would  have  failed  to  make  adequate  use  of,  is  shown  by 
a  circumstance  which  occurred  just  before  his  graduation.  The  college 
received,  too  late  to  utilize  for  the  session,  an  unclaimed  body  for  dis- 
section. There  being  no  means  for  preserving  it  Doctor  Gunn  was 
allowed  to  use  the  body  for  purposes  of  instruction.  He  packed  the 
body  in  a  large  trunk,  and  receiving  his  diploma  on  Tuesday,  left  his 
home  for  Ann  Arbor  on  the  Monday  following  the  day  of  his  gradua- 
tion. Two  weeks  after  leaving  home  he  made  his  arrangements  and 
commenced  lecturing  on  anatomy,  which  proved  so  successful,  that  in 
succeeding  years  he  repeated  this  course  accompanied  by  dissections 
and  demonstrations.  This  was  the  first  course  on  anatomy  ever  given 
in  Ann  Arbor,  and  probably  the  first  in  Michigan.  I  am  credibly 
informed  that  these  lectures  and  demonstrations  were  given  in  the 
basement  of  the  old  court  house  which  occupied  the  site  of  the  present 
building. 

In  July,  1849,  Doctor  Gunn  was  appointed  to  the  chair  of  Anatomy 
in  the  University  of  Michigan  to  which  was  added  the  Professorship 
of  Surgery  early  in  1850.  In  1854  it  was  deemed  advisable  that  Doctor 
Gunn  should  teach  only  Surgery,  and  in  June  of  this  year  Doctor 
Corydon  L.  Ford  was  appointed  to  fill  the  chair  of  Anatomy.  Thus 
at  last  the  youthful  dreams  of  these  two  enthusiastic  men  were  realized, 
one  taught  Anatomy  and  the  other  Surgery  in  the  same  medical  school. 
The  year  previous  to  his  appointment  by  the  Board  of  Regents — 1848 — 
Doctor  Gunn  married  Jane  Augusta  Terry,  only  daughter  of  J.  M. 
Terry,  M.  D.  The  fruits  of  this  union  were  four  children,  the  eldest 
of  whom,  Glyndon,  was  accidentally  drowned  in  the  Detroit  river  in 
the  summer  of  1866.  The  remaining  three  children  survived  their 
father. 

In  1853  he  changed  his  place  of  residence  from  Ann  Arbor  to 
Detroit,  where  he  remained  until  called,  in  1867,  to  Rush  Medical  Col- 


LIFE  OF  MOSES  GUNN.  63 

lege.  From  1853  to  1867  he  made  two  weekly  trips  to  Ann  Arbor, 
during  each  session,  to  deliver  his  lectures  on  Surgery.  Recognizing 
that  he  should  pattern  his  teaching  after  the  best  models  he  determined 
to  spend  the  winter  of  1849  and  1850  in  visiting  the  medical  schools 
and  hospitals  of  New  York,  Philadelphia,  and  Boston,  before  delivering 
his  first  course  of  lectures  at  Ann  Arbor  to  the  entering  class  consisting 
of  ninty-two  students.  I  cannot  refrain  from  quoting  some  of  Doctor 
Gunn's  keen  observations  upon  the  difference  in  the  mediqal  atmos- 
pheres respectively  of  Philadelphia  and  New  York.  He  justly  con- 
sidered that  Philadelphia  then  was,  from  the  medical  standpoint,  the 
Paris  of  America,  and  while  this  visit  preceded  my  student  days  some 
twenty-six  years,  in  my  time  this  was  equally  true.  "There  is  a  medical 
atmosphere  which  is  really  refreshing,"  says  he  in  a  letter  to  his  wife. 
"You  see  the  M.  D.'s  in  this  City  of  Brotherly  Love  have  a  kind  of. 
hospitality  peculiarly  their  own."  This  remark  was  evoked  by  the 
hospitality  that  men  who  had  won  great  names  in  medicine  accorded 
this  young  aspirant  for  fame,  such  men  as  Charles  D.  Meigs,  Joseph 
Pancoast,  John  Neill,  Professor?  Mutter  and  Homer,  all  insisting  upon 
his  accepting  numerous  social  invitations  and  making  him  free  of  their 
homes,  merely  because  he  was  a  member  of  the  same  profession. 
Doctor  Gunn  then  goes  on  to  say  in  this  same  letter,  "The  New  Yorkers 
have  a  good  deal  of  suavity,  but  the  politeness  of  the  Philadelphia 
doctors  is  extended  in  the  way  of  generous  hospitality,  and  almost 
every  member  of  the  profession  that  I  have  met  seems  to  be  imbuecf 
with  the  same  disposition.  As  I  said  before,  Philadelphia  contains  a 
medical  atmosphere  that  is  most  refreshing,  and  if  you  could  see  the 
way  the  doctors  do  it  up  here,  you  would  admire  the  profession  more 
than  you  now  do." 

Urged  by  patriotic  and  humanitarian  motives,  and  recognizing  the 
fact  that,  in  modern  parlance,  the  battlefield  was  one  of  the  surgeon's 
laboratories,  he  joined  the  Army  of  the  Potomac  on  September  i,  1861, 
as  Surgeon  to  the  Fifth  Michigan  Infantry,  remaining  in  the^service 
until  failing  health  compelled  him  to  resign  in  July,  1862.  Returning 
to  Detroit  during  a  three-weeks'  leave  of  absence,  in  December  and 
January,  1861-62,  he  crowded  into  this  time  his  quota  of  lectures  at 
Ann  Arbor  and  rejoined  at  Alexandria.  Leaving  this  place  with  his 
regiment  Doctor  Gunn  served  through  the  Peninsular  Campaign  until 
his  resignation  in  July,  1862. 

Like  many  other  men  at  that  time  he  was  an  enthusiastic  admirer  of 
General  George  B.  McClellan,  and  with  generous  indignation  expressed 
in  his  letters  his  opinion  of  the  politicians  who,  he  said,  marred  the 
General's  plans.  This  was  in  accordance  with  his  character,  for  if, 
after  what  he  considered  sufficient  deliberation,  he  arrived  at  an  opinion, 
to  this  he  would  cling  most  tenaciously,  notwithstanding  valid  argu- 
ments to  the  contrary.  This  trait  of  character  I  frequently  observed  in 
our  mutual  intercourse.  Both  as  an  illustration  of  his  capacity  of 
unburdening  his  mind  in  well  chosen  language,  as  well  as  to  call  atten- 
tion by  his  burning  words  to  the  unrewarded  heroism  of  the  profession 


64  ORIGINAL  ARTICLES. 

you  medical  students  are  about  to  enter  upon.  I  shall  quote  a  portion 
of  one  other  letter. 

"You  say  that  Mrs.  R.  complains  that  Surgeons  are  never  alluded 
to  after  a  battle.  No;  why  should  they  be?  Poor,  benighted  souls; 
did  anyone  dream  for  a  moment  that  a  surgeon's  field  had  aught  of 
glory  about  it?  No;  the  glory  consists  of  carnage  and  death.  The 
more  bloody  the  battle,  the  greater  the  glory.  A  surgeon  may  labor 
harder,  must  labor  longer,  may  exhibit  a  higher  grade  of  skill,  may 
exercise  the  best  feelings  of  our  poor  human  nature,  may  bind  up  many 
a  heart  as  well  as  limb,  but  who  so  poor  as  to  do  him  honor?  There  is 
ho  glory  for  our  profession.  We  may  brave  the  pestilence  when  all 
others  flee;  we  may  remain  firm  at  our  posts  when  death  is  more 
imminent  than  it  ever  was  on  the  battlefield ;  but  who  sings  our  praise  ? 
Does  the  world  know  who  the  physicians  were  who  fell  at  Norfolk 
when  yellow  fever  depopulated  that  town  ?  Does  it  know  who  rushed 
in  to  fill  their  places?  And  of  those  who  survived  can  it  designate 
one?  Did  they  survive  to  receive  fame?  Yet  those  men  were  braver 
than  the  bravest  military  leader,  for  theirs  was  bravery  unsupported 
by  excitement  or  by  the  hope  of  fame.  No ;  there  are  none  so  poor  as 
to  do  us  reverence.  And  thank  God  there  are  few  of  us  so  unsophis- 
ticated as  to  expect  it." 

While  this  is  lamentably  too  true,  yet  it  is  the  glory  of  our  profes- 
sion that  unlike  the  soldier,  striving  neither  for  glory  nor  for  promotion, 
the  medical  man  simply  does  his  duty  because  it  is  his  duty. 

I  cannot  refrain  from  citing  an  incident  in  order  to  impress  upon 
the  minds  of  medical  students  that  the  welfare  of  a  patient  should  be 
paramount  to  every  other  consideration;  Although  what  I  shall  relate 
happened  upon  the  battlefield,  as  has  just  been  pointed  out,  the  same, 
nay  a  higher  kind  of  courage  is  often  demanded  when  facing  disease, 
as  is  daily  done  by  the  rank  and  file  of  the  profession.  In  a  skirmish 
against  one  of  the  hill  tribes  on  the  frontier  of  India,  an  officer  was 
severely  wounded  in  advance  of  his  troops  as  dusk  was  coming  on. 
One  of  the  large  arteries  was  wounded  and  death  from  hemorrhage 
was  imminent.  The  surgeon  of  the  party  ran  forward  and  in  com- 
parative shelter  compressed  with  his  fingers  the  artery,  arresting  the 
bleeding.  While  the  location  of  the  fire  of  the  enemy  shifted,  it  con- 
tinued. Doubting  the  efficiency  with  which  he  was  compressing  the 
artery,  night  having  now  fallen,  the  surgeon  deliberately  lit  a  match 
instantly  causing  a  hail  of  bullets  to  fall  around  him,  and  then  finding 
his  patient  in  great  danger  of  being  wounded  a  second  time,  arranged 
an  efficient  makeshift  to  take  the  place  of  his  fingers  in  arresting  the 
bleeding,  picked  up  his  patient  at  the  greatest  risk  to  his  own  life, 
carried  him  to  the  rear,  tied  the  severed  artery,  and  saved  him !  What 
is  the  rush  forward  with  victorious  thousands  compared  to  such  an 
act  of  heroism?  I  am  glad  to  say  that  this  British  surgeon  received 
the  Victoria  Cross  for  Valor,  but  who  receives  any  recognition,  as  Gunn 
says,  when  deliberately  facing  death  from  loathsome  disease? 

Although  much  of  interest  remains  concerning  Doctor  Gunn*s  life 


LIFE  OF  MOSES  GUNN.  55 

at  this  time  which  would  be  instructive  and  interesting,  enough  has 
been  said  to  indicate  most  of  his  characteristic  mental  traits,  and  now 
it  behooves  us  to  briefly  consider  what  additional  qualities  rendered 
him  so  remarkable  as  a  teacher.  Although  from  the  purely  intellectual 
standpoint  the  physique  of  a  teacher  should  play  no  part  in  his  success, 
even  now\  a  stalwart  frame,  fine  voice,  an  impressive  and  commanding 
presence,  coupled  with  enthusiasm,  will  go  far  towards  securing  the 
attention  and  winning  the  confidence  of  scholars,  after  which  the  mental 
pabulum  offered  is  accepted  by  them  with  but  little  question. 

When  Doctor  Gunn  commenced  teaching,  in  this  country  an 
instructor  had  first  to  be  a  man  whom  manly  men  could  admire,  mere 
intellectual  force  alone  being  decidedly  at  a  disadvantage,  having 
slowly  to  win  attention  instead  of  compelling  it.  Gunn  and  men  of  his 
stamp  commanded  attention  and  confidence,  the  students  unconsciously 
placing  themselves  en  rapport  with  an  instructor  so  •  bounteously 
endowed  physically.  The  same  was  true  of  almost  all  the  great 
teachers  of  Surgery  of  Doctor  Gunn's  generation,  such  men  as  the 
elder  Gross,  Hunter  McGuire,  David  Yandell,  Edward  H.  ^^oore  and 
others  I  could  mention. 

1  shall  never  forget  how  I  was  impressed  by  my  first  sight  of 
Doctor  Gunn  twenty-three  years  ago.  Sauntering  along  the  street  a 
half  block  away  I  saw  the  striking  figure  of  a  man  considerably  over 
six  feet  in  height,  well  proportioned,  with  an  erect  military  carriage, 
clad  in  a  snugly-fitting,  carefully-buttoned-up  black  frock  coat,  his  head 
surmounted  by  a  high  black  silk  hat.  He  had  long  gray  side  whiskers, 
a  heavy  drooping  moustache,  and  curling  gray  hair  resting  upon  his 
coat  collar.  He  frequently  raised  his  gold-rimmed  eyeglasses  to  note 
the  architectural  peculiarities  of  each  house  he  approached,  every  street 
incident,  every  passer  by,  and  then  the  eyeglasses  were  allowed  to 
swing  from  their  long  gold  chain  to  be  again  quickly  readjusted  should 
anything  seem  worthy  of  attention.  Altogether  he  presented  an  impres- 
sive figure  of' a  man  of  physical  and  mental  power,  of  one  who  must 
investigate  everything  presented  to  his  senses,  who  quickly  observed, 
classified  his  impressions,  deciding  upon  the  respective  merits  and 
proper  relation  even  of  passing  events,  a  man  of  an  alert  and  enthu- 
siastic temperament,  ready  and  eager  to  digest  new  ideas,  yet  one  whose 
judgment  restrained  his  zeal  within  due  bounds.  The  essentials  of 
these  impressions  were  instantaneously  photographed  upon  my  mental 
retina  and  I  subsequently  found  them  to  be  accurate.  A  man  thus 
opulently  endowed  by  nature  and  trained  by  a  life  of  continuous 
effort  to  excel,  could  not  fail  to  command  at  the  very  outset  the  atten- 
tion and  confidence  of  any  audience,  and  to  exert  an  actively  compelling 
influence  over  them. 

The  modern  student  can  only  have  a  faint  conception  of  the  stress 
laid,  forty  or  fifty  years  ago,  upon  the  manner,  as  well  as  the  matter 
of  a  lecture.  At  the  present  time,  almost  any  form  of  expression  is 
permissible  that  the  speaker  believes  will  convey  his  ideas,  so  the 
naked  truth,  or  what  is  too  common,  truth  clad  in  ill-fitting,  actually 


56  ORIGINAL  ARTICLES. 

distorting  verbal  garments,  disgusts  or  fails  to  impress  the  hearer,  or 
more  often,  an  entirely  wrong  idea  is  conceived.  Slang,  catchwords, 
anything  will  do?  Qear  cut  thoughts  neither  will  be  nor  can  be 
expressed  in  crude,  slovenly  language.  A  careless,  loose  mode  of 
expression,  no  effort  being  made  to  clothe  ideas  in  appropriate  and 
decorous  speech,  is  always  an  evidence  of  ill-digested,  loose  thought; 
nay  more,  it  inevitably  leads  to  less  and  less  effort  being  made  to  think 
or  observe  clearly. 

Gunn  and  his  contemporaries  recognized  and  avoided  these  pitfalls. 
Careful  deliberation  was  employed  in  deciding  exactly  what  informa- 
tion was  to  be  given,  but  an  equal  effort  was  put  forth  in  securing 
fitting  language  to  convey  with  exactness  the  facts  to  be  considered. 
Let  none  think  that  it  was  pedantic  or  an  unnecessary  refinement  to 
mentally  alter  or  recast  phrases  before  giving  them  verbal  utterance, 
because  this  is  a  necessary  part  of  any  good  lecturer's  work.  Gunn 
and  his  successful  contemporaries  understood  the  necessity  of  so  lec- 
turing that  the  audience  did  not  become  dulled  by  constantly  listening 
to  nearly  the  same  phraseology  employed  to  convey  different  ideas,  and 
thus  lose  all  the  subtler  differences  in  scientific  values  because  of  the 
lack  of  nice  discrimination  in  the  language  employed  by  the  speaker. 
Happy  is  he  who  at  the  outset  possesses  a  large  vocabulary,  but  he 
must  never  lose  an  opportunity  to  add  to  his  store  of  words.  A  lec- 
turer who  conscientiously  searches  out  the  exact  word  or  phrase  to 
correctly  convey  a  given  idea  will  find  his  mental  vision  wonderfully 
clarified,  and  will  rarely  have  to  answer  questions  propounded  by  his 
mystified  class.  Let  me  give  you  an  illustration  of  the  plan  pursued 
by  another  of  our  great  teachers  of  the  past.  Doctor  Francis  Gumey 
Smith,  Professor  of  Physiology  in  the  University  of  Pennsylvania,  when 
I  was  a  student  there.  Two  hours  of  the  evening  preceding  the  lecture 
was  spent  in  consulting  authorities  and  refreshing  his  mind  as  to  experi- 
ments, et  cetera.  At  i  o'clock  the  next  afternoon  he  went  to  his  room 
at  the  medical  school,  read  over  the  stenographic  report  of  this  same 
lecture  delivered  during  a  previous  course,  saw  that  the  vivisections 
demonstrated  what  he  desired,  or,  that  the  experimental  apparatus  was 
working  properly,  and  then,  the  last  three-quarters  of  the  hour  pre- 
ceding his  5  o'clock  lecture  were  devoted  to  selecting  the  most  fitting 
language  to  employ  in  recapitulating  the  previous  lecture,  and  for  the 
lecture  about  to  be  delivered. 

Can  you  wonder  that  it  was  a  rare  treat  to  listen  to  such  a  speak- 
er's smoothly-flowing  sentences,  and  that  we  exactly  apprehended  what 
he  strove  to  teach  us?  And  this  expenditure  of  five  or  six  hours  in 
the  preparation  of  each  lecture  was  not  only  made  when  Doctor  Smith 
commenced  teaching,  but  after  twenty-five  years  of  practice.  Let  no 
one  think  that  it  is  unnecessary  to  thus  cut,  alter,  and  recast  phrases, 
for  to  such  precautions  do  I  attribute  much  of  the  successful  teaching 
of  years  ago. 

No  experienced  lecturer  thinks  it  beneath  him  to  search  until  he 
finds  the  exact  word  or  phrase  to  convey  a  given  idea,  even  if  he  has 


LIFE  OF  MOSES  GUNN.  57 

to  restate  that  which  he  has  already  presented  more  obscurely  to  his 
audience.  I  firmly  believe  that  if  some  of  the  present  opponents  of 
so-called  didactic  lectures  as  a  means  of  conveying  scientific  knowl- 
edge, could  have  listened  to  the  really  great  teachers  of  the  past,  much 
of  their  opposition  would  be  withdrawn.  But  to  attain  such  skill  is 
no  easy  task,  even  for  those  starting  with  unusual  endowments,  the 
aspirant  for  laurels  as  a  speaker  cannot  indulge  in  careless,  inaccurate 
language  in  ordinary  conversation,  or  in  his  correspondence.  These 
faults  were  conspicuously  absent  in  Doctor  Gunn.  I  have  read  many 
letters  of  his,  portions  of  some  of  which  you  have  listened  to,  and 
the  same  happy  lucidity  that  illuminates  his  more  pretentious  writings 
characterizes  his  family  correspondence.  He  thought  clearly  and  took 
the  trouble  to  always  employ  that  phraseology  which  compelled  his 
readers  or  hearers  to  apprehend  him  exactly.  Doctor  Gunn  as  a  lec- 
turer was  so  clear  in  his  rapid,  emphatic  statements  that  he  impressed 
his  auditors  with  his  thorough  mastery  of  his  subject.  He  was  a 
scholarly  and  accurate  speaker,  one  of  the  best  examples  of  the  old 
method  of  preparing  and  delivering  didactic  lectures.  Punctuality  in 
the  lecture  room  was  one  of  his  articles  of  religion.  His  superb  figure 
and  commanding  presence  at  once  centered  the  attention  of  the  class 
upon  him.  Doubtless  some  of  his  facility  as  a  speaker  and  writer  was 
due  to  his  connection  as  editor  with  the  Monthly  Independent  and  its 
successor,  the  Peninsular  and  Independent  Medical  Journal,  His  pub- 
lic clinical  work  was  his  chief  delight  and  his  reputation  was  largely 
due  to  these  lectures  and  his  operative  skill,  his  contributioris  to  lit- 
erature, as  we  shall  see,  unfortunately  being  few  indeed.  Full  of  fun 
and  anecdote,  which  he  often  most  skilfully  employed  to  fix  in  the 
minds  of  his  auditors  certain  facts  he  was  discussing,  he  was  never 
known  to  indulge  in  an  unclean  joke  or  allusion,  such  being  utterly 
abhorrent  to  his  nature.  If  the  occasion  demanded  some  mention  of 
the  errors  of  another  physician,  this  was  done  in  the  kindest,  most 
unobtrusive  manner.  He  was  absolutely  considerate  of  others  in  a 
consultation  and  was  never  known  to  speak  unkindly,  professionally, 
of  another  physician.  He  was  a  most  skillful  diagnostican,  and  arrived 
at  his  conclusions  with  startling  rapidity,  so  much  so  that  he  was 
unjustly  accused  of  being  careless.  Exactly  the  reverse  was  true,  but 
his  accuracy  of  observation  and  the  rapidity  of  his  mental  processes 
explain  the  ease  and  speed  of  his  diagnoses.  As  a  clinician  he  was 
above  everything  painstaking.  Every  step  of  an  operation  was  care- 
fully traced  out;  every  possible . complication  and  its  remedy  forseen 
and  provided  for;  every  instrument  or  appliance  was  mentally — as  it 
was  later  actually — set  aside  in  its  place;  everything  was  accurately 
mapped  out.  This  studious  observation  of  minute  details  secured  the 
remarkable  success  which  crowned  his  efforts.  His  frankness  in  deal- 
ing with  patients  was  conspicuous.  He  never  made  disingenious  or 
misleading  statements,  nor  would  he  consent  to  deceive  his  patients  as 
to  their  true  condition.  He  was  free  from  any  taint  of  dishonesty  with 
patient  or  practitioner.     On  one  occasion  a  consultation  was  being 


58  ORIGINAL  ARTICLES. 

held  over  an  obscure  case,  Doctor  Gunn  being  present.  When  asked 
his  opinion  he  replied:  "Gentlemen,  I  have  practiced  surgery  long 
enough  to  learn  that  it  is  a  wise  thing  in  a  doubtful  case  to  be  modest 
in  expressing  an  opinion.  I  do  not  know  what  this  tumor  is  and  I 
think  it  had  better  be  let  alone."  Duty  well  done,  his  whole  duty  to 
his  patient,  seemed  his  sole  guiding  motive.  When  once  asked  in  a 
note  handed  to  him  while  lecturing,  "What  is  a  doctor's  best  road  to 
success,"  he  replied  with  great  earnestness  and  solemnity,  "Young 
man,  your  best  road  to  success  is  to  deserve  to  succeed." 

His  judgment  as  an  operator  was  excellent.  He  possessed  a  cool 
head,  steady,  iron  muscles,  which  yet  could  wield  a  scalpel  like  an 
artist's  pencil,  and  above  all,  a  most  minute  and  accurate  knowledge  of 
anatomy.  With  such  endowments  and  that  supreme  self-confidence 
born  of  past  successes,  and  full  preparedness  for  any  emergency,  Gunn 
was  a  bold,  rapid,  brilliant,  and  at  the  same  time  neat  operator. 
Although  the  boldest  of  the  bold  when  occasion  arose,  as  we  have  seen 
he  was  in  reality  most  careful  of  the  indispensable  details  without 
which  disaster  so  often  must  come.  He  never  ceased  to  feel  the  burden 
of  responsibility  and  when  operating  would  permit  of  no  levity  of 
manner.  As  he  once  said  to  another  physician,  "I  never  can,  although 
I  often  wish  I  could,  divest  myself  of  anxiety  and  responsibility  in 
dangerous,  or  more  especially  troublesome  cases;  they  keep  me  in  a 
painful  state  of  concern."  His  mechanical  ability  was  pronounced; 
as  some  one  said.  "His  instrumental  paraphernalia,  straps,  and  splints 
and  bandages,  alw^ays  fitted  the  variety  of  the  species,  and  not  merely 
the  class  and  order." 

As  a  writer  Doctor  Gunn  wielded  a  facile  pen  which  lacked  neither 
force  nor  point.  He  employed  nice  discrimination  in  the  selection  of 
words,  so  that  he  was  a  remarkably  clear  writer,  while  his  style,  instead 
of  consisting  of  the  short,  staccato  sentence,  which  is  the  only  style 
some  men  can  employ  to  make  themselves  understood,  was  a  decidedly 
flowing  one,  pleasant  to  read,  yet  most  lucid.  He  possessed  to  an 
eminent  degree  that  indefinite  something  we  call  grace  of  diction.  He 
thought  so  rapidly  and  accurately  that  of  necessity  he  was  compelled 
to  employ  a  large  number  of  words,  and  in  perusing  his  articles  the 
reader  usually  overlooks  the  exceptionally  large  vocabulary  employed, 
and  wonders  why  he  understands  so  readily  sentences  that  sometimes 
contain  over  fifty  words.  His  thorough  reading  and  speaking  knowl- 
edge of  German,  and  an  excellent  acquaintance  with  French,  added  to 
the  range  of  his  literary  acquisitions,  hence  the  appropriateness  of  his 
illustrations  and  citations,  when  rapidly  pouring  forth  a  flood  of 
language,  was  remarkable. 

It  is  much  to  be  regretted  that  the  great  Chicago  fire  destroyed  the 
manuscript  of  a  work  on  Surgery  which  Doctor  Gunn  had  nearly 
completed.  Upon  the  Programs  you  will  find  the  titles  of  the  papers 
and  addresses  which,  with  numerous  editorials  published  in  the  journals 
of  which  he  was  editor,  and  discussions  of  the  papers  of  others  read 
before  the  American  Surgical   Association,  comprise  all  the  literary 


LIFE  OF  MOSES  GUNN.  59 

remains  bequeathed  to  us  by  Doctor  Gunn.  Of  their  value  none  can 
doubt,  and  especially  those  upon  the  "Philosophy  of  Certain  Disloca- 
tions of  the  Hip  and  Shoulder,  and  their  Reduction."  As  Doctor  Senn 
remarked,  "He  left  us  no  encyclopedia  of  medicine  but  his  little 
pamphlet  of  less  than  twenty-five  pages  contains  more  than  many 
others  have  compiled  in  bulkier  form." 

During  the  winters  of  185 1-2-3  Doctor  Gunn  made  numerous  dis- 
sections which  proved  that  the  untorn  portions  of  the  capsule  in  dis- 
locations of  the  shoulder  and  hip  were  the  cause  of  the  characteristic 
attitudes  assumed  by  the  limbs,  and  furthermore  were  the  true  obstacles 
to  reduction.  He  further  demonstrated  that  the  return  of  the  dis- 
located bone  to  its  socket  "can  be  easily  effected  by  putting  the  limb 
in  such  a  position  as  will  effectually  approximate  the  two  points  of 
attachment  of  that  portion  of  the  ligament  which  remains."  Doctor 
William  H.  Reid,  of  Rochester,  New  York,  on  May  8^  1850,  had 
described  a  method  of  reduction  by  manipulation  which  was  essentially 
one  procedure  which  is  yet  employed,  but  he  failed  to  point  out  cor- 
rectly the  obstacles  to  be  overcome  and  the  mechanism  of  the  reduction. 
Doctor  H.  J.  Bigelow,  of  Boston,  was  doubtless  familiar  with  Reid'? 
method  which  had  been  published,  in  connection  with  a  controversy 
excited  by  Reid's  original  paper,  in  the  Boston  Journal  about  1851-2. 
Doctor  Bigelow  continued  to  reduce  dislocations  on  the  cadaver  before 
the  medical  class  by  a  method  of  manipulation  from  1854  until  1861, 
believing  with  Reid  that  the  muscles  caused  the  fixed  attitude  of  the 
limb,  et  cetera.  Then,  as  Doctor  Bigelow  says,  "In  the  spring  of  1861, 
having  been  lead  to  expose  a  joint,  the  luxation  of  which  had  been 
the  subject  of  a  lecture,  I  was  agreeably  surprised  to  observe  the  sim- 
ple action  of  the  ligament, — a  simplicity  which  subsequent  experience 
has  confirmed,  and  which  strikingly  explains  the  phenomena  observed 
in  the  living  subject."  Had  Doctor  Bigelow  deigned  to  cast  his  eyes 
over  the  Peninsular  Journal  of  Medicine,  Ann  Arbor.  1853-4,  Volume 
I,  pages  95-100,  he  could  have  learned  all  the  facts  that  he  needed  to 
know,  which  had  been  deliberately  sought  for  and  discovered  by  the 
obscure  young  western  surgeon,  not  accidentally  seen,  as  Doctor 
Bigelow  states  was  the  fact  with  regard  to  his  own  discovery. 

There  can  be  no  question  that  to  Gunn  belongs  the  priority  of  dis- 
covery as  to  the  causes  of  the  characteristic  attitude  of  limbs  dislocated 
at  the  shoulder-  and  hip-joints,  what  the  obstacles  to  reduction  are,  and 
the  simple  principle  of  relaxing  these  unyielding  structures  by  position 
and  inducing,  without  force,  the  bone  to  retract  the  course  it  pursued 
when  escaping  from  the  stocket.  Although  everything  that  Gunn 
wrote  was  of  distinct  value,  his  reputation  as  an  investigator  and 
original  writer  must  depend  upon  this  admirable  piece  of  work. 

In  1856  Geneva  College  conferred  on  him  the  Honorary  degree  of 
M.  A.,  and  Chicago  University  that  of  LL.  D.  in  1877.  At  the  time  of 
his  death  Doctor  Gunn  was  an  active  member  of  the  American  Surgical 
Association,  of  the  American  Association  of  Genito-Urinary  Sur- 
geons, of  the  Illinois  State  Medical  Society,  of  the  American  Medical 


60  ORIGINAL  ARTICLES. 

Association,  of  the  Chicago  Medical  Society,  and  had  been  a  member 
of  several  of  the  Congresses  of  American  Physicians  and  Surgeons. 
He  served  as  surgeon  on  the  active  and  consulting  staffs  of  a  number 
of  charitable  institutions,  notably  the  Cook  County  Hospital,  Saint 
Joseph's  Hospital,  Saint  Luke's  Hospital, and  especially  the  Presbyterian 
Hospital,  intimately  connected  as  this  was  with  the  Rush  Medical  Col- 
lege, where  he  held  the  Chair  of  Surgery  for  nearly  twenty  full  years. 

On  the  fourth  of  November,  1887,  after  an  illness  of  some  weeks, 
this  noble  physician  passed  beyond  the  veil  to  his  well-earned  reward. 
He  was  a  lifelong,  consistent  and  faithful  member  of  the  Episcopal 
church,  belonging  to  the  old-fashioned  high  church  school.  Despite 
the  materialism  of  many  of  his  fellow-doctors,  he  said,  "I  often  doubt 
terribly,  but  I  say  to  myself,  I  looked  this  thing  all  over  once,  I  went 
through  the  arguments  and  I  decided  that  the  immense  balance  of 
testimony  was  in  favor  of  Christianity,  and  I  cannot  take  time  to  go  all 
over  it  again." 

Doctor  Gunn's  tenderness  to  his  child  patients  and  their  love  in 
return  for  him  was  very  striking.  His  fondness  for  animals,  flowers 
and  natural  beauty  was  strongly  developed  and  freely  indulged.  Unlike 
too  many  physicians,  he  did  not  permit  his  profession  to  absorb  and 
narrow  him,  if  for  no  other  reason,  lest  his  powers  as  a  practitioner 
and  teacher  should  be  crippled  thereby.  In  addition  to  the  study  of 
foreign  languages  and  the  literature  of  our  own  tongue,  Doctor  Gunn 
was  at  one  time  a  most  enthusiastic  and  well-informed  astronomer, 
thus  providing  himself  with  a  resource  which,  when  drawn  upon,  could 
bear  him  away  irom  his  daily  worries,  rest  his  mind,  and  serve  to 
elevate  his  thoughts  from  material  to  spiritual  things.  Well  would  it 
be  if  every  one  of  us  would  strive  for  ^me  form  of  knowledge  and 
culture  alien  to  that  of  our  profession.  Doctor  Gunn  was  fond  of  and 
shone  in  society  as  a  conversationalist,  now  one  of  the  nearly  lost 
arts. 

I  have  apparently  striven  thus  far  to  present  you  an  idealized 
picture  of  a  flawless  man,  which  none  of  us  believes  to  exist.  It 
remains  for  me  in  my  peroration  to  point  out  some  of  the  glaring 
defects  inseparable  from  a  character  such  as  I  have  endeavored  to 
depict.  He  was  imbued  rather  too  strongly  with  a  sense  of  self-respect, 
allied  to,  but  something  far  nobler,  than  conceit.  Conceiving  the  idea 
that  he  was  born  to  govern  in  many  things  he  sometimes  aspired  to 
command  outside  of  his  legitimate  sphere.  He  was  intolerant  of  argu- 
ment on  almost  any  subject,  and  often  did  scant  justice  to  his  opponents. 
He  could  be  bitingly  sarcastic,  and  resort  to  ridicule,  which,  as  I  once 
told  him,  was  not  argument,  and  totally  out  of  place  in  a  scientific 
discussion.  He  was  prompt  and  sharp  in  his  dealings  with  the  blunders 
and  shortcomings  of  anyone  who  failed  to  do  what  he  considered  was 
their  best.  In  some  things  he  was  radical  to  the  point  of  being  revo- 
lutionary. He  never  catered  for  popularity  by  shading  his  expressions 
of  opinion,  but  struck  as  l^ard  as  it  suited  him,  without  regard  for 
consequences.     In  his  determination  to  be  absolutely  honest  in  the 


LIFE  OF  MOSES  GUNN.  61 

expression  of  his  opinions  he  sometimes  appeared  harsh,  when  he  was 
really  actuated  by  the  best  motives.  While  tenacious  of  professional 
opinion,  he  never  claimed  to  be  able  invariably  to  correctly  diagnose 
the  innumerable  conditions  presented  for  his  consideration,  often 
quoting  to  the  students,  the  saying,  "if  your  foresight  was  as  good  as 

your  hindsight  you  would  not  make  so  many  mistakes  by  a  

sight."  He  was  an  ideal  consultant,  never  by  word  or  action  criticizing 
the  attendant  before  the  patient ;  if  he  had  anything  uncomplimentary 
to  say,  it  was  said  to  the  physician,  as  it  always  should  be,  in  private. 

To  sum  up,  then,  Gunn  was  a  notable  and  noble  figure  of  a  man, 
one  of  whom  the  profession  and  especially  this  school  has  good  reason 
to  be  proud.  An  honest,  high-toned,  unselfish,  Christian  gentleman; 
a  hater  of  shams  in  any  form;  a  good  son,  husband  and  father;  an 
example  of  devotion  to  the  noblest  of  professions,  and  through  it  a 
benefactor  of  humanity ;  our  most  illustrious  Founder,  one  whom  every 
student  present  should  strive  to  emulate. 

And  now,  shade  of  a  most  gallant  and  knightly  physician,  whose 
shield  was  so  often  successfully  interposed  between  his  intended  victims 
and  the  Grim  Destroyer — Death,  farewell.  May  the  example  of  your 
life  shine  as  a  beacon  light  to  lead  us  on  to  nobler  endeavor,  and  may 
the  voice  of  your  teachings  long  continue  to  "echo  through  the  cor- 
ridors of  Time." 

I  append  the  following  list  of  his  writings : 

"Philosophy  of  Certain  Dislocations  of  the  Hip  and  Shoulder,  and  their 
Reduction."  Peninsular  Journal  of  Medicine,  Ann  Arbor,  1853-4,  Volume  I, 
pages  95-IOO- 

Reprinted  with  some  additions  in  the  same  journal  1855-6,  Volume  III, 

pages  27-35. 
Reprinted  in  pamphlet  form,  1855. 
Reprinted    with    further    additions    in    the    Peninsular    and  Independent 

Medical  Joumctl,  1859-60,  Volume  II,  pages  193-206. 
Reprinted  in  pamphlet  form  1859. 
Second  edition  printed  in  1869. 
"Selections   from   Surgical   Notes."    Medical  Independent,   Detroit,    1857-8, 
Volume  III,  pages  67,  186,  257,  377,  469,  575- 

"Selections  from  Surgical  Notes."  Peninsular  and  Independent  Medical 
Journal,  Detroit,  1858-9,  Volume  I,  pages  464-467;  1859-60,  Volume  II,  pages 
140-143. 

Doctor  Gunn  was  one  of  the  ^editors  of  the  Monthly  Independent,  Detroit, 
1857-8,  Volume  III,  and  of  the  Peninsular  and  Independent  Medical  Journal, 
1858-9,  Volume  I;  and  1859-60,  Volume  II;  and  was  the  author  of  numerous 
editorials  in  these  journals,  usually  signed  "G." 

"Address  of  Welcome  to  Rush  Medical  College,"  delivered  October  i,  1867, 
Chicago  Medical  Journal,  1867,  Volume  XXIV,  pages  499-512. 

"Valedictory  Address,  Rush  Medical  College,"  1870-71.  Ibid.,  1871,  Volume 
XXVIII,  pages  157-169;  also  reprinted. 

"Surgical  Clinic  of  Rush  Medical  College."  Ibid..  1874,  Volume  XXI. 
pages  560,  725. 

"Discussion  of  Doctor  Gross'  Paper  on  Syphilis."  "Transactions  American 
Medical  Association,"  Philadelphia,  1874.  Volume  XXV,  page  243. 


62  ORIGINAL  ARTICLES. 

"Case  of  Traumatic  Tetanus,  Saint  Joseph's  Hospital."  Chicago  Medical 
Journal  and  Examiner,  1875,  Volume  XXXII,  pages  421-426. 

"Address  in  Surgery  and  Anatomy,"  delivered  May  8,  1879.  "Transactions 
American     Medical     Association,"    Philadelphia,     1879,    Volume    XXX,    pages 

79-493. 

"Report  of  a  Case  of  Purulent  Effusion  into  Knee-joint."  Ibid.,  1879,  Vol- 
ume XXX,  page  517- 

"Treatment  of  Fractures  of  the  Skull,  Recent  and  Chronic,  with  Depres- 
sion." Read  June  i,  1882.  "Transactions  of  the  American  Surgical  Associa- 
tion," 1881-83.     Philadelphia,  1883,  Volume  I,  pages  83-90. 

"The  Doctorate  Address  on  Medical  Ethics."  Chicago  Medical  Journal  and 
Examiner,  1883,  Volume  XLVI,  pages  337-352.    Also  reprinted. 

"The  Philosophy  of  Manipulation  in  the  Reduction  of  the  Hip  and  Shoulder 
Dislocations."  "Transactions  American  Surgical  Association,"  (1884)  1885, 
Volume  II,  pages  399-519;  also  in  Chicago  Medical  Journal  and  Examiner,  1874, 
Volume  XLVI II,  pages  449-468.     Also  reprinted. 

"The  Union  of  Nerves  of  Different  Function  Considered  in  its  Pathological 
and  Surgical  Relations."  Address  of  the  President  delivered  April  28,  1886, 
Volume  IV,  pages  1-13. 


BORDERLAND  CASES  OF  INSANITY.* 
By  IRWIN  li.  NEFF,  M.  D..  Pontiac,  Michigan. 

ASSISTANT  PHYSICIAN  AT  THB  KASTBBN  MICHIGAN  ASYLUM   POR  THB  INSANB. 

The  subject  which  I  have  chosen  is  not  an  uninteresting  one. 
Many  cases  of  questionable  insanity  have  been  reported  and  valuable 
information  has  been  obtained.  A  reference  to  the  literature  on  this 
subject  will  show  a  voluminous  bibliography.  My  intention  is  not  to 
particularize,  but  to  correlate  some  of  our  knowledge  on  this  subject 
and  isolate  a  few  of  its  practical  aj>plications, — facts  which  would 
appeal  to  the  interest  of  the  general  practitioner. 

Borderland  cases,  correctly  speaking,  would  comprise  all  those  cases 
in  which  the  alleged  irresponsibility  of  the  individual  is  unproven.  As 
is  well  known  such  a  definition  would  include  a  number  of  conditions, 
and  it  is  true  that  many  and  diverse  symptoms  accompany  such  a  case. 
It  is  obvious  that  one  considering  a  "borderland  case"  must  be  con- 
versant with  both  normal  and  abnormal  psychology.  As  it  is  admitted 
that  the  origin  of  the  moral  sense  has  no  fixed  period,  we  see  that 
a  priori  we  have  a  task  of  no  little  importance. 

I  would  also  call  attention  to  the  fact  that  we  are  in  danger  of  going 
to  the  extreme.  On  one  hand  we  have  the  ruling  of  the  criminologists 
and  students  of  sociology ;  and  again  we  are  confronted  with  the  state- 
ment of  the  extremist,  who  declares  that  since  the  degree  of  respon- 
sibility cannot  always  be  defined,  everyone  should  have  an  equal  chance, 
and  that  consequently  we  should  show  leniency  when  occasion  demands. 
Many  attempts  have  been  made  to  prove  or  disapprove  these  statements, 
but  it  must  be  acknowledged  that  we  have  reached  no  conclusioo  which 
can  give  satisfaction. 

*Kead  at  the  Ann  Arbor  meetins^  of  the  First  Councilor  District  Medical 
Society,  December  22,  1905. 


BORDERLAND  CASES  OF  INSANITY.  63 

For  a  settlement  of  this  perplexing  question  we  naturally  turn  to  the 
alienists  and  criminologists.    Let  us  see  what  they  have  to  contribute. 

Our  conception  of  insanity  today  is  vastly  different  from  our  idea 
of  the  psychosis  twenty-five  years  ago,  and  this  is,  in  great  part,  owing 
to  our  improved  clinical  interpretation  of  mental  disorders.  Much  of 
the  mystery  surrounding  practical  psychiatry  has  vanished,  ,we  hope 
forever.  A  careful  study  of  a  number  of  cases  has  shown  that  a 
grouping  of  cases  is  possible,  thereby  making  the  nomenclature  of 
insanity  possible,  and  simplifying!  it  to  a  remarkable  degree.  We  have 
also  more  correct  and  definite  explanatory  terms,  and  have  brought 
closer  together  the  relationship  of  the  neurosis  to  the  psychosis.  And, 
lastly,  I  would  call  attention  to  the  relationship  of  bodily  conditions  and 
mental  disturbances.  Although  we  believe  that  in  insanity  the  essential 
condition  is  a  disordered  action  of  the  brain,  we  admit  that  the  causes 
producing  such  a  disruption  may  be  dependent  upon  bodily  disease  or 
defect.  It  is  not  strange,  considering  these  revelations,  that  the  psy- 
chiatrists should  demand  a  more  careful  study  of  these  cases.  They 
believe  that  a  more  painstaking  inquiry  into  each  individual  case,  along 
certain  definite  lines,  would  be  of  material  assistance  in  clearing  up 
the  vexed  question  of  "responsibility." 

A  review  of  the  writings  of  alienists  on  the  vexed  question  of 
"responsibility"  will  show  that  there  is  quite  a  uniform  opinion  on  the 
question  of  its  restriction.  According  to  a  number  of  prominent 
alienists  diminished  responsibility  is  to  be  charged  in  cases  of  even 
slight  mental  affections,  in  incipient  stages  of  others  (as  in  that  of 
general  j>aralysis),  in  some  psychic  degenerations,  without  delirium, 
in  borderland  cases  of  insanity,  cases  of  sexual  perversion,  chronic 
alcoholism,  neurasthenia,  the  general  epilepsies,  and  in  certain  cases 
of  the  other  neuroses. 

Mercier  claims  that  there  is  a  certain  sphere  of  activity,  in  which 
every  insane  individual  is  to  be  held  irresponsible,  but  outside  of  which, 
any  act  of  his  may  be  punishable  by  law,  so  that  but  a  few  insane  can 
be  held  entirely  irresponsible.  Mercier  inclines  to  the  idea  that  the 
physician  should  not  be  permitted,  as  such,  to  decide  on  the  degree  of 
responsibility  in  these  cases,  but  should  simply  and  clearly  describe 
the  patient's  mental  state,  leaving  to  the  judge  the  application  of  the 
law  (Journal  of  Nervous  and  Mental  Disease,  Volume  XXIX,  page 

739). 

The  criminologist,  proceeding  in  much  the  same  way  a§  the  alienist, 
has  discovered  truths  which  have  proven  to  be  of  practical  importance. 
As  is  well  known  the  relation  of  crime  to  insanity  has  been  the  nucleus 
on  which  has  been  built  our  present  knowledge  of  the  criminal.  It 
has  been  definitely  decided  that  there  is  a  true  relation, — a  relation, 
which  like  insanity  in  some  of  its  respects,  is  difficult  to  analyze. 

In  order  to  emphasize  these  statements,  and  wishing  to  show  con- 
certed opinion  in  regard  to  the  responsibility  of  the  criminal,  I  give 
the  following  quotation :     Doctor  W.  B.  Noyes,  writing  on  the  "Crim- 


64  ORIGINAL  ARTICLES. 

inal  Equivalent  of  Insanity,"  says  that  "the  importance  of  fixed  idea  or 
obsession  on  obscure  cases  in  crime  cannot  be  too  frequently  brought 
to  the  attention  of  jurists,  and  the  presence  of  minor  eccentricities  is 
also  important,  for  there  is  no  sharp  line  to  be  drawn  between  the 
eccentric  and  criminal  action."  Such  mental  eccentricities,  Noyes 
believes,  are  often  as  clearly  stigmata  of  degeneration  as  the  more 
definitely  understood  physical  stigmata.  He  also  speaks  of  the  crim- 
inal, who  knows  both  concrete  and  abstract,  but  lacks  what  he  calls 
"hidden  or  ethical  feeling."  "Such  a  man  knows  right  and  wrong, 
but  will  not,  on  that  account,  be  kept  from  committing  wrong." 

The  practical  application  of  these  facts  is  possible,  but  united  and 
uniform  action  is  called  for.  It  is  obvious  that  there  can  be  no  fixed 
rule  in  "borderland  cases,"  but  it  is  nevertheless  true  that  our  judg- 
ment is  called  for,  and  our  opinion  must  be  rendered.  It  is  true  that 
our  medical  opinions,  which  should  be  respected,  are  often  overruled ; 
but  we  should  never  hesitate  to  give  our  verdict,  even  to  the  extent  of 
frankly  acknowledging  our  inability  to  render  more  than  a  conservative 
opinion. 

The  necessity  for  expert  testimony  in  these  borderland  cases  is 
apparent.  It  i^  unquestionable  that  medical  expert  testimony  would 
be  less  severely  condemned  if  only  the  physician  familiar  with  mental 
trouble  would  consent  to  testify.  An  alleged  case  of  insanity  cannot 
be  hastily  decided  upon,  for  the  diagnosis  should  not  be  placed  on  the 
existence  of  a  delusion  or  the  presence  of  some  peculiarity,  alone.  The 
diagnosis  of  mental  disease  should  rather  be  dependent  on  the  sum  of 
bodily  and  mental  defects,  and  the  proper  correlation  of  facts  gained 
by  a  thorough  study  of  the  patient. 

Naturally  the  determination  of  insanity  in  a  "borderland  case" 
requires  the  most  exquisite  care.  The  case  must  be  most  carefully 
considered  and  extended  examinations  are  often  demanded.  When 
summoned  to  examine  such  a  case  the  physician  must  remember  the 
character  of  insanity  and  appreciate  the  difficulties  which  he  will 
encountei-.  The  psychiatrist  knows  that  the  case  requires  a  most  care- 
ful handling,  and  that  he,  in  all  probability,  will  be  met  with  opposition, 
which,  if  he  is  not  experienced,  may  affect  his  final  decision.  One 
should  also  bear  in  mind  that  although  the  practical  grouping  of  the 
insanities  is  now  possible,  cases  are  found  which  cannot  be  relegated 
to  any  one  particular  gjoup.  Nevertheless  such  cases  are  cases  of 
insanity.  The  physician  should  not  hesitate  to  so  declare  it,  giving  his 
specific  reasons  and  acknowledging  his  inability  to  classify  it.  It  must 
also  not  be  forgotten  that  insanity  is  a  protean  disease,  and  it  may  be 
that  the  peculiarity  exhibited  by  the  patient  is  a  prodromal  or  primary 
symptom  of  a  well  recognized  form  of  insanity.  We  should  never 
arrive  hastily  at  our  conclusion,  and  one  must  remember  that  when 
undertaking  such  a  case  he  has  set  for  himself  a  task  which  will  require 
both  tact  and  perseverance. 

(i)  Insanity  is  a  protean  disease.  Its  syndrome  is  subject  to 
variation,  and  a  grouping  is  not  possible  in  all  cases. 


CLINICAL  SOCIETY.  66 

CONCLUSIONS 

(2)  Borderland  cases  of  insanity  are  at  times  more  apparent  than 
real.  A  consideration  of  such  cases  may  show  that  the  obscure  s)rmp- 
tom  is  really  an  early  manifestation  of  a  psychosis,  which  can  be  classi- 
fied. 

(3)  Medical  men  when  testifying  in  "borderland  cases"  should 
invariably  give  their  reasons  for  their  opinion,  and  should  not,  if  there 
is  not  sufficient  proof,  attempt  to  isolate  the  symptom  and  refer  it  to  a 
named  psychosis. 

(4)  The  degree  of  responsibility  in  some  of  these  cases,  considering 
our  present  knowledge,  cannot  be  accurately  determined.  Every  case 
is  a  study  in  itself,  and  must  be  determined  on  its  merits. 

(5)  Expert  testimony  should  be  given  only  by  experts.  If  this 
rule  was  strictly  adhered  to  medical  expert  testimony  would  be  better 
appreciated. 

(6)  Inability  to  pass  upon  a  case  should  be  frankly  acknowledged. 
In  cases  of  doubt,  we  are  justified  in  giving  our  testimony,  and  leaving 
the  real  decision  of  responsibility  to  the  court  and  its  representatives. 


TRANSACTIONS. 


CLINICAL  SOCIETY  OF   THE   UNIVERSITY  OF  MICHIGAN. 


STATED  MEETING,  DECEMBER  15,  1905. 

The  President,  ROGER  S.  MORRIS,  M.  D.,  in  the  Chair. 
Reported  by  DAVID  M.  KANE,  M.  D.,  Secretary. 

REPORTS  OF  CASES. 
CARDIAC  ANEURYSM, 

Doctor  George  Dock  :  I  wish  to  describe  a  case  of  cardiac  aneur- 
ysm. The  patient  was  a  farmer  of  fifty-two  years,  of  intemperate  hab- 
its, and  with  a  scar  suggestive  of  syphilis  but  denial  of  history  of 
infection.  From  the  age  of  eighteen  the  patient  complained  of  neuralgic 
pain  in  the  pit  of  the  stomach  and  of  pain  and  tenderness  in  the  heart 
region.  Two  years  before  death  he  had  a  slight  paralysis  of  the  right 
side,  lasting  only  three  hours.  For  the  last  four  months  of  life  pain  in 
the  heart  region  was  more  severe,  paroxysmal,  and  sometimes  radiating 
down  the  left  arm.  Unlike  most  patients  with  angina  pectoris,  the  man 
became  almost  maniacal,  running  around  the  room,  screaming,  declar- 
ing that  the  pain  would  kill  him,  but  without  having  the  oft-described 
feeling  of  impending  death.  For  the  last  two  months  the  pain  in  the 
heart  was  almost  continuous.  There  was  dyspnea;  edema  coming  on 
first  in  the  lower  extremities,  then  becoming  general.  Physical  exam- 
ination showed  all  the  evidences  of  incompensation,  the  heart  dilated 


66  ORIGINAL  ARTICLES. 

and  hypertrophied,  with  a  blowing  systolic  murmur  at  the  apex.  The 
second  aortic  was  accentuated;  the  radial  arteries  tortuous,  thick, 
slightly  uneven;  the  liver  reached  to  the  navel  line;  urine — specific 
gravity  1015,  one-fourth  bulk  albumin,  few  hyaline  casts.  For  several 
weeks  he  had  not  been  able  to  sleep.  Under  the  influence  of  morphine, 
diuretin  and  salt-free  diet  the  patient  improved  markedly,  so  that  by 
the  second  day  of  treatment  he  was  able  to  sleep  lying  down.  In  four 
days  the  edema  was  gone  and  the  heart  became  smaller.  Eight  days 
after  beginning  treatment,  against  positive  orders  to  the  contrary  and 
with  a  prediction  of  sudden  death  in  the  event,  he  ate  a  large  meal, 
started  out  for  a  walk,  but  after  going  a  block,  fell  over  and  was  found 
to  be  dead.  Autopsy  showed  adhesions  over  the  front  part  of  the  left 
ventricle ;  the  heart  enlarged,  containing  an  aneurysm  at  the  end  of  the 
left  ventricle,  and  in  the  septum,  containing  a  thrombus  partly  old  and 
partly  recent.  There  was  relative  insufficiency  of  the  mitral  valve, 
slight  thickening  of  aortic  flaps,  coronary  sclerosis,  with  obliteration  of 
the  anterior  coronary  in  the  lower  part.  The  other  organs  showed  con- 
gestion, slight  atrophy,  with  moderate  parenchymatous  and  interstitial 
changes. 

Doctor  Dock  gave  a  critical  summing-up  of  the  case  with  reference 
to  symptomatology,  diagnosis,  prognosis  and  treatment.  He  also  called 
attention  to  some  of  the  points  of  interest  in  connection  with  the  subject 
of  sudden  death,  and  gave  a  detailed  account  of  the  history  of  cardiac 
aneurysm  from  the  time  of  Lancisi.  His  remarks  were  illustrated  by 
a  number  of  old  and  modem  works  on  heart  disease,  including  Cor- 
visart,  Laennec,  Cruveilhier,  Carswell,  and  also  some  of  the  more 
important  articles  in  medical  periodicals  illustrating  the  development  of 
our  knowledge  of  cardiac  aneurysm. 

OVARIAN  CYST  WITH  TWISTED  PEDICLE. 

Doctor  Christopher  G.  Parnall:  Gynecological  case  number 
1408  was  admitted  to  the  University  Hospital  on  September  21,  1905. 
Age  forty-two ;  married  nineteen  years. 

Family  History. — Negative. 

Personal  History. — Had  all  the  ordinary  diseases  of  childhood  with 
good  recoveries.  For  many  years  she  has  had  attacks  of  headache. 
Patient  says  she  has  never  been  real  well. 

Menstrual  History. — Menses  appeared  at  age  of  twelve.  Last  period 
seven  weeks  before  admission.  Very  irregular,  one  to  two  months. 
Duration,  one  to  two  days.  Amount  scanty,  one  or  two  napkins  for 
whole  epoch.     No  pain.     Moderate  vaginal  discharge. 

Marital  History. — No  children.     No  history  of  abdrtions. 

Present  Trouble. — It  began  about  three  years  ago  with  pain  in  both 
groins,  worse  on  left  side.  The  abdomen  increased  in  size  very  slowly. 
The  enlargement  seemed  to  be  general  and  not  confined,  even  at  first, 
to  either  side.  At  the  last  menstrual  period  there  was  severe  pain  in 
the  lower  abdomen  beginning  on  the  right  side  and  extending  to  the 


CLINICAL  SOCIETY  67 

left  There  is  a  history  of  a  number  of  attacks  similar  to  the  above 
except  that  the  pain  was  not  so  severe.  No  nausea  nor  vomiting. 
Patient  does  not  think  she  had  ferer. 

Examination, — There  is  a  great  development  of  adipose  tissue, 
patient  weighing  two  hundred  and  thirty  pounds.  Otherwise  the  gen- 
eral examination  is  negative.  There  is  a  marked  abdominal  enlarge- 
ment extending  from  the  pubes  upwards  to  the  epigastrium.  This 
swelling  is  dome-shaped.  Lineae  albicantes  marked.  There  is  a  deep 
suprapubic  transverse  furrow,  above  which  the  tumor  is  dome-shaped, 
smooth  and  symmetrical.  It  is  sensitive  and  somewhat  movable.  Per- 
cussion note  is  dull  over  the  tumor,  tympanitic  in  the  flanks.  No  fluid 
wave.  Vaginal  examination  shows  the  uterus  retroverted.  Append- 
ages not  palpable.  Nothing  can  be  made  out  in  the  fomices  of  the 
vagina. 

On  the  day  after  admission  the  examination  of  the  urine  revealed 
a  positive  test  for  sugar.  On  a  so-called  carbohydrate-free  diet  the 
sugar  disappeared.  The  patient  was  kept  on  diabetic  diet  for  a  week 
preceding  operation,  during  which  time  there  was  no  reappearance  of 
the  glycosuria. 

Diagnosis. — Ovarian  cyst.  On  account  of  the  sensitiveness  and 
history  of  sudden  attacks  of  pain,  it  was  thought  probable  that  a  twist 
of  the  pedicle  would  be  found,  possibly  with  adhesions  of  the  cyst  wall 
to  the  surrounding  peritoneum,  and  infection  of  the  contents. 

Operation. — On  September  25,  1905,  by  Doctor  Peterson.  The 
abdcHnen  was  opened  by  an  incision  thirteen  centimeters  long,  in  the 
median  line.  The  subcutaneous  fat  was  six  and  one-half  centimeters 
in  thickness.  On  opening  the  peritoneum  it  was  found  that  the  cyst 
wall  was  adherent  to  it  for  a  radius  of  about  ten  centimeters.  The 
adhesions  were  thin  and  vascular.  They  were  loosened  by  sweeping 
the  hand  between  the  cyst  wall  and  the  peritoneum.  About  nine  liters 
of  muddy-colored  fluid  were  removed  by  the  trocar.  The  cyst  was  then 
easily  removed  by  clamping  the  pedicle,  which  was  twisted  counter- 
clockwise for  half  a  turn.  The  left  ovary  was  enlarged  and  cystic  and 
was  removed.  The  uterus  was  held  forward  by  ventro-suspension. 
Four  days  after  operation  sugar  again  was  found  in  the  urine  and  did 
not  entirely  disappear  under  diabetic  diet.  The  wound  healed  satis- 
factorily and  convalescence  was  uninterrupted. 

This  case  is  of  interest  from  the  standpoint  of  diagnosis.  Twist 
of  the  pedicle  of  an  ovarian  cyst  is  not  uncommon,  still  the  condition 
often  goes  unrecognized. 

The  torsion  may  be  acute,  resulting  in  severe  sudden  symptoms,  or 
chronic,  with  less  marked  changes.  In  the  first  variety  there  is  a 
sudden  cutting  off  of  the  blood  supply,  particularly  on  the  venous  side, 
and  hemorrhage  into  the  cyst.  Acute  torsion  may  resemble  in  many 
ways  the  rupture  of  an  ectopic  gestation  sac.  There  is  usually  sudden 
severe  pain  coming  on  after  exertion,  movements  of  the  bowels,  or 
urination.  The  patient  may  faint  and  present  signs  of  internal  hem- 
orrhage. 


68  ORIGINAL  ARTICLES. 

In  the  chronic  form  the  torsion  is  slow,  the  circulation  in  the  tumor 
is  interfered  with  only  gradually,  and  adhesions  often  form  between 
the  cyst  wall  and  the  neighboring  V^lvic  organs  or  the  parietal  peri- 
toneum. The  cyst  may  thus  obtain  a  large  share  of  its  blood  supply 
through  these  adhesions. 

The  temperature  is  usually  not  much  elevated,  generally  ioo°  to 
102°  Fahrenheit.  The  pulse  in  acute  torsion  is  frequently  very  rapid, 
ranging  from  100  to  160  per  minute.  When  there  is  a  marked 
adhesive  peritonitis  vomiting  is  a  prominent  symptom.  Intestinal 
obstruction  may  occur  as  a  result  of  the  inflammatory  changes  involv- 
ing the  cyst  and  intestines  or  frcxn  pressure  of  the  tumor.  Palpation 
in  uncomplicated  cases  of  ovarion  cyst  is  accomplished  without  causing 
even  discomfort.  In  case  of  adhesions  involving  the  Serous  mem- 
branes there  is  abdominal  rigidity  and  marked  sensitiveness.  A  small 
right-sided  adherent  cyst  may  indeed  be  easily  mistaken  for  appen- 
dicitis or  periappendical  inflammation. 

A  CASE  OF  ACUTE  CHOREA. 

Doctor  Theophil  Klingmann:  All  the  facts  which  have  been 
gathered  by  the  pathological  anatomist  and  the  physiological  chemist 
in  the  study  of  chorea  offer  no  explanation  of  the  defects  that  give  rise 
to  the  condition.  No  constant  lesions  have  been  found.  Although 
certain  organic  changes  are  often  associated  with  the  disease,  it  is  not 
infrequent  to  observe  cases  that  are  truly  functional  and  give  support 
to  the  view  that  chorea  is  an  expression  of  functional  instability  of 
those  nerve  centers  which  have  assigned  to  them  the  office  of  con- 
trolling the  motor  apparatus.  Of  the  actual  nature  of  this  derange- 
ment we  know  little  or  nothing;  whether  the  fault  is  primarily  in  the 
cortical  cells  or  whether  the  impulses  are  secondarily  disturbed  in 
their  course  down  the  motor  path.  Hereditary  influence  is  discover- 
able in  many  cases  of  chorea.  A  neuropathic  heredity  has  been  found 
in  one-sixth  of  the  cases.  Frequently  a  double  relationship  of  the  dis- 
ease can  be  traced  to  acute  rheumatism  on  the  one  hand  and  to  various 
nervous  disorders  on  the  other. 

The  case  in  question,  a  patient  of  good  general  appearance,  twenty- 
four  years  of  age,  gives  evidence  of  hereditary  influence.  The  father 
of  the  patient  has  had  rheumatism.  We  must  not,  however,  lay  too 
much  stress  upon  this  fact,  as  rheumatism  is  so  common  that  it  is  only 
significant  when  the  family  tendency  is  very  strong,  or  when  the  sub- 
ject has  endured  much  suffering  from  the  disease.  The  mother  of  the 
patient  died  at  the  age  of  thirty-six,  of  pulmonary  tuberculosis.  One 
sister  died  of  the  same  disease  at  the  age  of  thirty.  Another  sister 
had  chorea  for  several  months  at  the  age  of  fourteen,  but  recovered 
completely.  The  patient's  health  was  good  until  her  eighteenth  year, 
when  she  became  somewhat  nervous  and  fretful  and  complained  of 
forgetfulness.  She  recovered  from  this  condition  without  treatment, 
however,  and  was  quite  as  well  as  ever  until  the  present  affection  began. 
She  experienced  her  first  attack  of  chorea  three  years  ago,  when  she 


CLINICAL  SOCIETY.  09 

was  twenty-two  years  of  age  and  four  months  past  her  third  confine- 
ment. Her  first  pregnancy  terminated  prematurely  at  seven  months; 
the  second  four  years  ago  at  full  term;  the  third  and  fourth  preg- 
nancies also  being  at  regular  time.  The  nervous  condition  at  first 
manifested  itself  in  severe  headaches  and  marked  irritability,  which 
was  followed  by  involuntary  muscular  movement  in  the  face,  the  tongue, 
and  later  in  the  upper  and  lower  extremeties.  This  continued  for  about 
two  months  and  ended  in  complete  recovery.  One  year  later  she  had 
a  second  attack.  This  siege  was  much  less  severe  and  lasted  but  a 
short  time.  She  became  pregnant  soon  after  this  attack  and  remained 
well  until  five  months  after  confinement,  when  a  third,  the  most  severe 
attack,  developed. 

The  patient  came  to  the  University  Hospital  in  November,  1905. 
She  had  suffered  frc«n  chorea  since  August  without  intermission. 
While  her  general  appearance  is  fairly  good  she  has  lost  about  thirty 
pounds  since  the  beginning  of  this  attack.  There  is  no  apparent  cause 
for  this  loss  of  weight  except  continual  worry  and  anxiety  together 
with  annoyance  incident  to  constant  involuntary  muscular  contractions. 
Her  sleep  is  very  much  disturbed.  There  is  no  disturbance  of  diges- 
tion. The  appetite  is  good.  The  patient  is  not  anemic.  In  fact  there 
is  no  evidence  of  organic  disease  in  any  organ  except  the  heart,  and 
the  lesion  indicated  gives  the  patient  no  discomfort.  There  is  con- 
siderable muscular  weakness  present.  The  spontaneous  movements 
and  incoordination  are  most  marked  in  the  arms  and  hands,  but  the 
face,  and,  to  some  extent,  the  lower  extremities,  were  likewise  affected. 
The  movements  are  very  irregular  as  to  time  as  well  as  in  character 
and  degree.  Sensibility  is  not  disturbed  and  there  is  no  pain  or 
tenderness  in  any  part  of  the  body.  The  mental  state  is  normal. 
The  cardiac  symptoms,  which  are  the  only  evidence  of  organic  disease 
in  the  case,  are  of  great  importance.  The  frequency  of  organic  disease 
of  the  heart  is  less  in  childhood  than  in  youth.  In  chorea,  developing 
late,  as  it  did  in  this  patient,  the  cardiac  symptoms  are  usually  those 
of  organic  disease  and  frequently  mitral  regurgitation.  It  is  reported 
that  in  nine  out  of  every  ten  fatal  cases  the  cardiac  valves  are  diseased. 
Statistics  in  the  various  clinics  show  that  distinct  organic  disease 
either  preceding  or  developing  during  the  course  of  chorea  was  found 
in  thirty-two  per  cent  of  the  cases.  What  part  this  plays  as  a  causative 
factor  cannot,  with  our  present  knowledge  of  the  disorder,  be  ascer- 
tained. The  changes  which  have  been  found  after  death  afford  no 
clear  indication  that  the  circulation  is  primarily  deranged.  In  the 
majority  of  cases  of  the  common  form  of  chorea  the  heart  lesion  gives 
the  patient  little  or  no  discomfort,  even  though  it  persists  after  the 
involuntary  muscular  movement  has  entirely  ceased.  The  same  is  true 
of  other  pathologic  conditions  occurring  before  or  during  the  course 
of  the  disease.  It  seems  more  likely  that  one  common  cause  disturbs 
the  functions  of  the  various  organs  of  the  body,  as  well  as  the  functions 
of  the  nerve  centers  in  the  brain.  This  cause  may  possibly  be  found 
in  some  toxin  which  accumulates  in  the  organism.     This  is  borne  out 


70  ORIGINAL  ARTICLES. 

by  the  fact  that  treatment  directed  to  improve  elimination  through  the 
bowels,  kidneys,  and  skin  will  relieve  the  symptoms  greatly.  Further 
evidence  is  given  by  the  fact  that  the  conditions  with  which  chorea  is  so 
frequently  associated  are  caused  by  autointoxication.  We  must  not 
lose  sight  of  other  etiologic  factors  in  the  treatment  of  this  disease. 
There  is  a  distinct  predisposing  influence  of  much  importance.  Chorea 
occurs  most  frequently  during  later  childhood  when  the  functional 
develojMnent  of  the  nerve  centers  has  been  effected,  but  the  exercise 
thereof  has  not  yet  secured  stability  of  function,  leaving  them  very 
susceptible  to  outside  influences.  The  normal  restlessness  of  childhood 
manifests  the  predisposition  to  chorea.  With  this  predisposition  is  to 
be  associated  the  important  fact  that  emotion  has  been  frequently  the 
exciting  cause.  In  the  case  under  consideration  the  condition  devel- 
oped rather  late,  but  at  a  time  when  considerable  strain  was  brought 
to  bear  upon  an  unstable  nervous  system  by  the  responsibility  of  a  child 
and  other  household  duties,  not  to  forget  the  untoward  effects  of  a 
premature  labor. 

When  the  patient  came  to  the  hospital  it  was  markedly  evident  that 
both  nutritk>n  and  elimination  were  defective.  The  first  attention, 
therefore,  was  given  to  these  pathologic  states.  The  patient  was  put  to 
bed  and  kept  at  rest.  Oiloral  hydrate  was  adijainistered  in  ten-grain 
doses  every  three  or  four  hours  to  the  extent  of  controlling  the  involun- 
tary muscular  movements,  and  in  addition  five  to  ten  drops  of  Fowler's 
solution  were  given  three  times  a  day.  At  present  the  patient  is  ahnost 
well.  The  choreic  movements  are  slightly  noticeable  in  the  hands,  but 
otherwise  have  entirely  disappeared.  Under  this  treatment  the  duration 
of  the  disorder  is  usually  short  and  the  prc^^osis  extremely  favorable. 


CLINICAL  SOCIETY  OF  THE  NEW  YORK  POLYCLINIC. 


STATED  MEETING,  JANUARY  8,  1906. 

The  President,  JOHN  J.  MacPHEE,  M.  D.,  in  the  Chair. 
Reported  by  FREDERICK  C.  KELLER,  M.  D.,  Secretary. 

READING  OF  PAPERS. 
THE  TREATMENT  OF  SYPHILIS, 

Doctor  Andrew  R.  Robinson  read  a  paper  on  this  subject.  He 
referred  to  the  different  views  held  on  the  subject  of  the  treatment  of 
syphilis,  and  stated  that  he  would  endeavor  to  show  that  syphilis  is  a 
serious  disease  in  a  considerable  percentage  of  cases,  and  especially  on 
account  of  the  tendency  after  immunity  is  reached  to  fatal  parasyphilitic 
affections;  that  the  tendency  to  these  parasyphilides  depends  as  a 
special  predisposing  factor  upon  the  dyscrasic  condition  accruing  in  the 
active  contagion  stage;  that  the  intoxication  producing  the  dyscrasia 
and  leading  to  immunity  often  is  most  severe  in  the  period  between  the 
recognition  of  the  primary  sore  and  the  appearance  of  lesions  upon  the 


CLINICAL  SOCIETY.  71 

cutaneous  surface,  and,  therefore,  that  syphilis  should  be  treated  actively 
as  soon  as  a  positive  diagnosis  of  the  disease  is  made. 

The  object  of  such  treatment  is  to  inhibit  the  life  action  of  the 
organism,  so  that  only  a  small  amount,  comparatively,  of  toxin  is  pro- 
duced, giving  immunity  with  only  a  mild  dyscrasia,  and  producing  a 
minimum  amount  of  injury  to  the  tissues  and  consequently  a  compara- 
tively slight  tendency  to  parasyphilides  or  even  tertiary  lesions.  He 
maintained,  also,  that  in  the  acute  infectious  stage  it  is  a  rule  that  the 
less  toxin  produced  in  a  given  case,  the  earlier  the  system  acquires  the 
condition  of  immunity ;  and  in  syphilis  this  is  important  not  only  for 
the  individual  affected,  but  also  from  a  social  standpoint,  as  the  sooner 
immunity  is  obtained  the  less  danger  of  contagion  to  others. 

An  example  of  early  immunity  is  that  acquired  by  a  mother  in  a 
case  of  parental  syphilis,  when  she  is  not  invaded  by  the  syphilitic 
organisms,  but  acquires  immunity  by  toxins  from  the  fetus.  Under 
these  circumstances  the  amount  of  toxins  passing  to  the  mother  must 
be  small  in  quantity  and  therefore  the  immune  condition  is  acquired  in 
a  comparatively  short  period  as  compared  with  the  time  necessary  in 
acquired  syphilis. 

Syphilis  is  a  serious  disease,  not  only  on  account  of  the  liability  to 
fatal  parasyphilitic  affections,  as  locomotor  ataxia,  but  also  on  account 
of  its  destructive  action  on  the  progeny  of  syphilitic  parents  when  pro- 
duced during  the  active  stage  of  the  disease,  hence  the  shorter  this 
period  exists  the  fewer  syphilitic  children  are  produced. 

If  the  tertiary  parasyphilides  depend  very  greatly  or  principally 
upon  the  severity  of  the  dyscrasia,  and  this  condition  upon  the  amount 
of  intoxication,  that  is,  the  amount  of  toxins  produced,  and  this  upon 
the  number  and  activity  of  the  syphilitic  organisms  in  the  system,  it 
follows  that  in  this  special  parasitic  affection  the  treatment  of  syphilis 
must  be  based  upon  the  microbes,  the  toxins  produced,  and  the  ground 
of  the  individual  affection.  Proper  consideration  of  these  three  points 
constitutes  the  fundamental  basis  for  the  best  treatment  of  the  disease. 

Syphilis  is  a  continuous  condition  from  the  time  of  infection  until 
the  last  microbe  is  gone ;  hence  the  division  of  the  disease  into  stages  is 
not  scientifically  correct,  although  for  clinical  description  it  is  of  some 
value. 

In  the  period  between  the  appearance  of  the  primary  sore  and  the 
so-called  secondary  stage,  represented  by  cutaneous  lesions,  the  general 
nutrition  of  the  person  is  lowered,  fever  is  present  in  varying  degree, 
the  red-blood  corpuscles  are  diminished  in  number,  the  lymph  glands 
throughout  the  body  may  be  affected,  the  spleen  swollen  and  tender, 
I  liver  enlarged  and  the  nervous  system  injured,  as  shown  by  the  pres- 

ence of  neuralgia,  headache,  lassitude,  pains  in  the  joints,  bones,  and 
j  periosteum,  and  occasionally  by  an  extensive  multiform  erythematous 

eruption.  This  shows  that  before  secondary  lesions  occur  upon  the 
skin  there  may  be  intoxication  of  the  general  system,  which  leaves  its 
impress  on  the  tissues  and  acts  as  the  main  disposing  factor  in  the 


72  ORIGINAL  ARTICLES. 

^causation  of  parasyphilides.  If  this  be  true,  it  follows  that  treatment 
should  be  commenced  in  every  case  as  soon  as  a  positive  diagnosis  is 
made,  and  if  this  is  done  at  a  stage  before  cutaneous  lesions  appear, 
so  much  the  better  for  the  patient. 

Existing  lesions  in  the  secondary  stage  are  treated  to  lessen  danger 
of  contagion,  remove  deformity  and  save  tissue,  but  surely  it  is  better, 
more  philosophical,  to  prevent  the  formation  of  lesions,  especially  as 
they  are  hotbeds  for  toxin  formations,  than  to  wait  until  they  are 
formed  and  damage  has  occurred.  The  treatment  of  syphilis  should 
be  offensive,  not  defensive.  Keep  the  disease  in  as  quiescent  a  state  as 
possible  by  inhibiting  the  life  action  of  the  organism ;  prevent  contagion 
from  lesion  formation ;  promote  the  elimination  of  the  toxins  as  quickly 
and  completely  as  possible,  and  pay  attention  to  the  general  nutrition 
of  the  patient.  This  constitutes  the  correct  treatment  of  syphilis  accord- 
ing to  our  present  knowledge. 

Mercury  is  the  only  agent  that  acts  upon  the  microbe,  hence  it 
should  be  given  during  the  entire  microbic  stage  in  such  manner  as  to 
secure  the  best  action.  lodid  of  potassium  should  be  given  only  as  an 
aid  to  the  mercury  or  as  an  alternative  in  later  stages  and  at  all  times 
when  tertiary  lesions  are  present.  It  is  rarely  indicated  during  the  first 
six  months  of  the  disease,  and  never  during  the  microbic  stage,  as  the 
only  agent. 

Against  the  parasyphilides  one  should  produce  a  proper  degree  of 
alkalinity  of  the  system,  advise  avoidance  of  everything  that  causes 
circulatory  disturbances  and  of  things  that  interfere  with  tissue  metab- 
olism, especially  alcohol,  local  irritating  agents,  et  cetera. 

DISCUSSION. 

Doctor  Edward  L.  Keyes,  Jr.  :  While  I  agree  with  all  the  conclu- 
sions reached  by  the  author,  I  disagree  wholly  with  all  the  premises. 
Briefly,  in  his  opinion,  the  way  to  treat  syphilis  is  as  a  disease  and  not 
as  an  array  of  symptoms.  The  most  practical  method  is  to  settle  in 
one's  mind  the  amount  of  medicine  considered  necessary  in  all  cases  to 
overcome  the  disease.  One  grain  of  iodide  of  mercury  every  day  for 
three  years  will  conquer  it,  and  even  though  the  skin  lesions  have  disap- 
peared, together  with  the  mucous  patches  in  the  throat  and  all  other 
outward  manifestations,  the  physician  should  still  try  to  live  up  to  his 
ideal  of  the  amount  of  mercury  or  iodid  that  should  be  taken  by  the 
patient,  whether  he  stands  it  well  or  not.  I  disagree  absolutely  with  the 
speaker  regarding  the  method  of  treatment  at  the  beginning  of  syphilis. 
It  is  extremely  dangerous  to  proclaim  that  syphilis  should  be  treated 
before  the  appearance  of  a  cutaneous  lesion,  because,  in  a  very  fair  pro- 
portion of  cases,  one  is  unable  to  make  a  positive  diagnosis  until  the 
appearance  of  the  secondary  lesions.  Theoretically,  if  it  is  proved  that 
the  existence  of  the  spirocheta  pallida  is  conclusive  of  syphilis,  treat- 
ment may  begin  as  soon  as  it  is  recognized,  but  until  this  is  possible, 
it  is  wiser  to  wait  for  secondary  evidence.     I  recall  two  instances  in 


CLINICAL  SOCIETY.  73 

which  patients  who  presented  themselves  for  treatment  within  twelve 
hours  of  the  supposed  inoculation  had  developed  a  chancre  six  weeks 
later. 

Doctor  Charles  H.  Chetwood  :  There  seems  to  be  a  general  ten- 
dency at  the  present  time  to  question  whether  syphilis  should  be  treated 
in  the  primary  or  in  the  secondary  stage.  The  reader  of  the  paper  has 
emphasized  the  point  that  the  question  is  not  when  to  treat  it,  but  that 
it  should  be  treated  when  the  diagnosis  has  been  made.  For  my  part, 
I  have  always  treated  it  when  the  secondary  eruption  appeared,  and 
consider  it  a  safe  procedure.  I  would  not  advise  commencing  treatment 
earlier  unless  the  presence  of  the  disease  should  be  positively  substan- 
tiated by  the  spirocheta  pallida  or  some  other  germ.  I  treat  all  cases 
according  to  the  general  exigencies  of  each  individual  condition,  and 
the  results  have  been  most  satisfactory. 

Doctor  Joseph  H.  Abraham  :  Next  to  the  dermatologist  and  the 
genitourinary  surgeon,  the  nose  and  throat  specialist  sees  as  many  cases 
of  syphilis  as  any  of  the  specialists.  They  rarely  see  any  primary  syph- 
ilis, but  many  secondary  and  tertiary  cases  come  to  their  notice.  Per- 
sonally, I  have  seen  five  cases.  One  patient  had  the  initial  lesion  on  the 
lip  and  the  other  four  on  the  tonsils,  and  in  one  case  the  upper  respira- 
tory glands  showed  marked  symptoms  of  intoxication.  Another  marked 
feature  is  the  enlargement  of  the  leutic  glands.  I  agree  with  the  prin- 
ciples laid  down  by  the  reader  of  the  paper  for  the  treatment  of  primary 
syphilis.  Secondary  syphilis  of  the  larynx  should  be  treated  entirely 
by  personal  rule.  I  rely  upon  one  drug,  carbolic  acid.  An  application 
of  ten  per  cent  chromic  acid  to  the  larynx  gives  rise  to  practically  no 
pain  and  accomplishes  the  desired  result.  If  the  patient  is  given  a 
sufficient  amount  of  mercury  for  a  long  enough  period  of  time,  he  is 
less  liable  to  require  the  iodides  or  to  suffer  from  a  marked  tertiary 
form  later.  I  have  never  found  it  necessary  to  give  more  than  seventy- 
five  or  eighty  grains  of  the  iodid  at  one  dose,  and  always  begin  with 
five  grains  and  increase  one  grain  daily  or  every  other  day.  The  absorp- 
tion occurs  as  desired  and  the  digestive  tract  is  not  disturbed. 

Doctor  Robert  H.  M.  Dawbarn  :  I  believe  the  wisest  course  is  to 
begin  treatment  of  syphilis  as  soon  as  one  is  sure  of  the  character  of 
the  lesion.  I  do  not  agree  with  the  statement  that  the  iodid  of  potas- 
sium has  no  direct  bearing  upon  the  foundation  of  syphilis.  In  my 
opinion,  overeating  and  overdrinking  may  so  change  the  metabolism  of 
the  hunian  system  as  to  render  the  effects  of  syphilis  more  intoxicating. 

Doctor  John  A.  Bodine:  The  time  to  begin  treatment  depends 
greatly  on  the  character  of  the  patient.  The  primary  duty  of  the  phy- 
sician is  to  effect  a  cure.  If  the  patient  is  a  highly  intelligent  one,  the 
treatment  may  begin  as  soon  as  the  diagnosis  is  positively  made,  as 
that  character  of  patient  may  be  depended  upon  to  carry  the  treatment 
through  to  its  logical  conclusion.  With  a  more  ignorant  patient,  it  is 
often  necessary  to  first  convince  him  that  he  is  a  victim  of  this  disease 
in  order  to  impress  upon  him  the  necessity  for  systematic  and  long- 


74  ORIGINAL  ARTICLES 

continued  treatment  and  in  this  case  the  appearance  of  the  skin  erup- 
tion following  the  sore  convinces  him  that  he  has  syphilis. 

Doctor  Robinson  :  I  still  think  the  treatment  should  be  begun,  if 
possible,  during  the  first  stage  of  the  disease.  If  the  patient  presents 
what  he  considers  the  initial  lesion,  I  recommend  a  six  weeks'  course 
of  treatment  with  mercury,  and  if,  at  the  end  of  that  time,  there  remains 
any  question  as  to  the  diagnosis,  it  is  very  easy  to  bring  out  a  small 
lesion  as  convincing  proof. 

REPORTS  OF  CASES. 
URETHRAL  FISTULA  AND  PROLAPSED  KIDNEYS, 

Doctor  Charles  H.  Chetwood:  I  wish  to  show  a  patient  on  whom 
I  operated  two  years  ago  for  urethritis,  and  who  at  the  present  time 
has  an  incomplete  fistula.  When  first  examined  his  symptoms  seemed 
to  point  toward  the  urethra  and  prostate,  the  latter  being  about  the  size 
of  a  small  orange  and  very  hard.  The  history  indicated  a  gonorrheal 
infection,  and,  apparently,  a  syphilitic  abscess  of  the  prostate.  The 
patient  urinates  every  half  hour,  day  and  night,  and  the  bladder  con- 
tains about  twelve  ounces  of  residual  urine.  The  appearance  of  the 
urine  is  indicative  of  kidney  pus.  Both  kidneys  are  prolapsed  and  the 
right  one  is  very  palpable,  enlarged  and  tender.  The  interesting  feature 
of  the  case  is  the  prolapse  of  both  kidneys  without  any  apparent  explan- 
ation. There  is  no  tuberculous  history  and  none  suggestive  of  kidney 
disease.  My  intention  is  to  drain  the  prostatic  abscess  through  a  per- 
ineal incision,  examine  the  bladder  through  the  opening,  and  possibly 
catheterize  one  of  the  ureters. 

SYRINGOMYELIA  OR  LEPROSY f 
Doctor  John  A.  Bodine:  I  desire  to  present  this  patient.  She  is 
twenty-one  years  of  age,  and  her  family  history  is  negative.  About  six 
years  ago  she  first  noticed  that  she  was  unable  to  distinguish  the  impact 
of  the  soles  of  her  feet  against  the  sidewalk  and  began  to  have  aching 
pains  in  her  feet  and  legs.  Later,  pus  formed  beneath  callous  spots  on 
the  feet  and  discharged,  leaving  sinuses  leading  down  to  the  metatarsal 
bones.  Rest  in  bed  healed  the  sinuses,  but  on  resumption  of  her  occupa- 
tion they  reopened.  Pain  was  present  in  her  spine  from  the  neck  to 
the  coccyx.  She  was  operated  on  for  contractures  of  the  feet  in  1902. 
Her  general  health  is  now  fair.  The  soles  of  her  feet  are  covered  with 
multiple  perforating  ulcers.  The  discharge  is  thick,  brownish  in  color, 
and  has  a  peculiar  sickening,  penetrating  odor.  There  is  an  abscess 
under  the  skin  in  one  thigh  and  another  over  the  sacrum.  There  are 
marked  motor  and  sensory  disturbances  of  the  feet  and  legs.  The  case 
is  presented  for  diagnosis,  which  I  think  lays  between  syringomyelia 

and  leprosy. 

discussion. 

Doctor  William  B.  Pritchard  :  I  consider  this  patient  an  example 
of  syringomyelia  presenting  the  exception  in  a  distribution  of  symptoms 
in  the  lower  rather  than  the  upper  extremities,  though  both  are  involved. 

The  trophic  disturbances  in  the  feet,  with  bladder  symptoms,  scoli- 


MALTA  FEVER.  76 

osis,  and,  finally,  dissociation  sensory  phenomena,  indicate  with  fair 
clearness  the  diagnosis.  It  is  not  a  leprous  neuritis,  as  the  nerves  show 
no  bulbous  enlargements  and  the  skin  is  quite  free  from  the  characteris- 
tic plaques.  Tabes  has  been  suggested,  but  there  is  little  in  the  symptom 
picture  to  sustain  such  a  suggestion.  Absence  of  the  Argyll-Robertson 
pupil,  the  persistence  of  one  knee-jerk,  with  absence  of  true  ataxic  gait 
and  characteristic  pains  were  collectively  conclusive  in  negation. 

ORIGINAL  ABSTRACTS. 


MEDICINE. 

By  GEORGE  DOCK,  A.  M.,  M.  D.,  D.  Sc,  Ann  Arbor,  Michigan. 

PltOFBSSOII  OF  MBOBCim  IM  TMB  VMIVmMTT  09  MICHIGAM. 
AND 

DAVID  MURRAY  COWIE,  M.  D.,  Ann  Arbor,  Michigan. 

riR^T  ASSISTANT  IN  UBOICINB  IN  TMS  VNIVUISITV  OW  MICMIOAN. 


MALTA  FEVER. 
Charles  F.  Craig  ("International  Clinics,"  Volume  IV,  Fifteenth 
Series,  page  89)  gives  a  brief  but  very  valuable  study  of  this  interesting 
disease,  based  upon  twelve  cases  observed  by  himself.  One  of  the 
twelve  seems  to  have  acquired  the  disease  in  Washington,  District  of 
Columbia,  the  first  recorded  as  originating  in  the  United  States.  None 
were  fatal ;  all  but  one  had  had  one  or  more  previous  attacks ;  seven  pre- 
sented acute  exacerbations,  five,  chronic  symptoms.  Craig  finds  the 
symptomatology  so  complex  that  no  case  can  be  considered  as  abso- 
lutely typical.  The  most  marked  symptom  and  the  one  most  complained 
of  is  severe  pain  in  the  muscles  and  around  the  joints.  In  acute 
cases  it  was  most  intense  in  the  lumbar  regions  and  the  extremities.  In 
chronic  cases  it  was  generally  localized  around  one  or  more  joints,  was 
paroxysmal,  often  leaving  one  joint  and  appearing  in  another.  The 
temperature  curve  is  not  so  characteristic  as  has  been  believed.  In  first 
attacks  the  undulant  type  occurs,  with  a  gradual  rise,  gradual  fall,  and 
several  days  of  normal  temperature.  But  even  in  acute  cases  such  tem- 
perature curves  are  the  exception.  "In  the  majority  of  cases  .  .  . 
the  temperature  curve,  instead  of  being  an  aid  to  diagnosis  is  the 
reverse,  and  is  the  chief  cause  of  mistaken  diagnosis."  There  is  an 
anemia,  with  leucocytosis,  the  white  count  ranging  from  16,000  to  as 
high  as  28,000,  the  increase  being  in  the  polynuclears.  The  kidneys 
seem  to  escape  injury ;  even  albuminuria  is  rare.  Pain  and  swelling  of 
the  joints  do  not  usually  occur  in  first  attacks,  but  during  the  second, 
third  or  fourth;  rarely  not  at  all.  There  is  moderate  swelling,  with 
some  reddening  of  the  skin.  The  skin  is  hot ;  there  is  great  tenderness 
on  pressure,  but  no  effusion  can  be  detected.  The  most  valuable  aid  to 
diagnosis  is  the  agglutination  test  with  micrococcus  melitensis,  first 
observed  by  Wright,  of  Netley,  and  in  high  dilutions — preferably  i  75. 


76  ORIGINAL  ABSTRACTS. 

The  reaction  is  marked  and  immediate.  Craig  has  never  found  the 
reaction  in  any  other  disease ;  it  failed  him  once  in  an  undoubted  case. 
Malaria,  typhoid  fever,  tuberculosis,  pneumonia,  septicaemia  and 
pyaemia,  relapsing  fever,  and  Hodgkin's  disease  and  articular  rheuma- 
tism must  be  differential.  The  author  suggests  a  wider  distribution 
for  Malta  fever,  even  in  temperate  latitudes,  than  is  generally  supposed. 

OLD. 


SURGERY. 

By  frank  BANGHART  WALKER,  Ph.  B.,  M.  D.,  Detroit.  Michigan. 

ntOVBaOOII  op  SUWLGWMX  and  OPBRATIVB  SUHCBftT  IN  THE  OBTKOIT  POSTGRADUATB  SCHOOL  OP  UBDICINB.' 
ADJUNCT  PKOPBSSOR  OP  OPBKATIVB  9URGBRY  IN  THB  DBTROIT  COLLBGB  OP  MBDICINB. 

AND 

CYRENUS  GARRITT  DARLING.  M.  D,  Ann  Arbor.  Michigan. 

CUNICAL  PROPBSSOR  OP  9URGBRT  EN  THB  UNIYRRSITY  OP  MICHIGAN. 


SCOPOLAMINE  AS  AN  ANESTHETIC  AID. 

Without  championing  any  anesthetic  or  mode  of  anesthesia, 
Royster  sums  up  in  Surgery,  Gynecology,  and  Obstetrics  for  February, 
1906,  his  experience  with  fifty  cases.  He  believes :  ( i )  That  ether  is 
our  safest  general  anesthetic;  (2)  That  ethyl  chloride  secures  the  pleas- 
antest  primary  narcosis;  and  (3)  That  the  preliminary  use  of  scopola- 
mine with  morphine  increases  the  patient's  mental  resisting  power  and 
lessens  the  quantity  of  ether. 

From  its  use  clinically  the  writer  does  not  regard  scopolamine  iden- 
tical with  hyocine.  He  believes  it  safe  in  proper  doses,  not  to  exceed 
one  one-hundredth  of  a  grain.  This  dose  he  has  sought  to  use  with 
one-sixteenth  grain  of  morphia  about  one  hour  before  the  time  set  for 
the  operation.  When  the  patient  is  brought  in,  primary  anesthesia  is 
induced  in  about  one  minute  by  ethyl  chloride  sprayed  6n  several  layers 
of  gauze  folded  over  nose  and  mouth.  The  ether  cone  is  then  used  and 
the  patient  is-  ready  in  four  or  five  minutes.  This  method,  appar- 
ently complicated,  he  states  is  really  simple  and  produces  sleep  safely, 
swiftly,  and  sweetly.  He  does  not  regard  scopolamine  harmless,  how- 
ever, two  cases  having  caused  his  anesthetizer  to  doubt  whether  he 
should  proceed.  f.  b.  w. 


GYNECOLOGY. 

By  REUBEN  PETERSON,  A.  B..  M.  D.,  Ann  Arbor,  Michigan. 

PltOPBSSOK  OP  GTNBCOLOGT  AND  OB8TBTKXCS  IN  THB  UNIVBIISITY  OP  MICHIGAN. 

AND 

CHRISTOPHER  GREGG  PARNALL,  A.  B.,  M.  D..  Ann  Arbor.  Michigan. 

PIRST  ASSISTANT  IN  GTNBCOLOGT  AND  OBSTBTRICS  IN  THB  UNIVBRSITT  OP  MICHIGAN. 


THE  TREATMENT  OF  ABORTION. 

BoLDT    (Journal  of  the  American  Medical  Association,  Volume 

XLVI,  Number  H)  considers  at  length  the  treatment  of  abortion  in  its 

various  stages.     He  divides  abortion  into  four  classes,  that  is:   (i) 

Imminent  abortion,  in  which  the  symptoms  may  subside  on  treatment; 


ORIGIN  OF  TUBERCULOSIS  IN  CHILDREN.  77 

(2)  Progressing  abortion,  when  the  expulsion  of  the  ovum  cannot  be 
prevented;  (3)  Incomplete  abortion,  when  the  contents  of  the  uterus 
are  partially  expelled,  some  portion  still  being  retained;  (4)  Complete 
abortion. 

The  treatment  of  imminent  abortion  consists  in  absolute  rest  in  bed 
and  the  administration  of  morphine  or  codeine  as  necessary.  Tampons, 
ergot,  and  ice-bags  are  to  be  avoided  on  account  of  the  liability  of  start- 
ing up  uterine  contractions. 

Progressing  and  incomplete  abortion,  in  the  absence  of  symptoms 

of  sepsis,  are  to  be  treated  by  first  giving  a  hot  antiseptic  vaginal  douche 

[  and  then  firmly  packing  the  vagina  with  gauze.     After  twenty-four 

j  hours  the  gauze  is  removed  and  usually  the  products  of  conception  are 

!  found  free  in  the  vagina.     In  case  the  os  is  well  dilated  and  the  ovum 

still  remains  in  the  uterus  it  may  be  possible  to  introduce  the  finger 

and  effect  a  manual  removal,  or  the  vaginal  packing  failing,  the  cervix 

and  lower  uterine  segment  may  be  tamponed  and  the  vagina  filled  with 

gauze;  the  subsequent  procedures  being  the  same  as  after  vaginal 

packing  alone.     Should  the  bleeding  be  severe  when  the  patient  is  first 

seen,  it  is  inadvisable  to  adapt  the  above  plan.     Instead,  the  cervical 

canal  should  be  dilated  sufficiently  if  not  already  patulous  and  the 

ovaum  or  retained  decidua  removed  by  the  finger  or  with  a  placenta 

forceps.     Ergot  may  then  be  given. 

Complete  abortion  requires  no  treatment  except  rest  in  bed,  vulvar 
irrigation,  and  the  usual  measures  carried  out  with  puerperal  cases. 
Curetment  to  remove  the  decidua  is  unnecessary  and  hence  inadvisable. 

If  there  is  bleeding  several  weeks  after  a  supposed  abortion  the 
uterine  cavity  should  be  examined  and,  if  necessary,  curetted.  When 
evidences  of  infection  are  present,  the  uterine  cavity  should  be  emptied 
as  completely  as  possible,  whether  the  ovum  has  been  spontaneously 
expelled  or  not.  A  curet  should  be  used  to  remove  adherent  infected 
membranes  or  decidua,  and  an  antiseptic  intrauterine  douche  carefully 
given.  Great  caution  is  always  necessary  in  curetting  the  uterus  after 
an  abortion. 

The  general  tenor  of  the  article  is  in  advocacy  of  a  conservative, 
expectant  method  of  treatment  in  all  noninfected  cases  of  abortion. 
The  author  is  of  the  opinion  that  much  harm  has  come  from  a  tendency 
on  the  part  of  many  practitioners  to  adopt  really  dangerous  methods  of 
interference  in  simple  cases.  c.  g.  p. 


PEDIATRICS. 

By  ARTHUR  DAVID  HOLMES,  M.  D..C.  M.,  Detroit,  Michigan. 


ORIGIN  OF  TUBERCULOSIS  IN  CHILDREN. 

Hynds  (Virginia  Medical  Semi-Monthly,  May,  1905)  observes  that 

tuberculosis  in  children  is  a  more  frequent  occurrence  than  is  commonly 

supposed.     Fisher  says  that  one-third  of  the  deaths  of  childhood  are 

due  to  tuberculosis  in  some  form  or  another,  and  more  frequent  under 


78  ORIGINAL  ABSTRACTS. 

the  age  of  four  years.  The  bones,  joints  and  lymph  glands  are  the  parts 
most  frequently  affected.  Its  great  prevalence  in  children  during  the 
milk-drinking  age  and  the  predominance  of  other  types  than  the  pulmon- 
ary would  seem  to  indicate  a  bovine  origin  and  in  communities  where 
the  milk  was  Pasteurized  the  percentage  of  intestinal  forms  was  less 
than  in  districts  where  the  milk  was  fed  raw.  The  British  Commission 
found  that  the  tuberculosis  produced  in  cattle  by  material  from  human 
and  bovine  sources  was  identical  in  its  general  effect  and  in  detail. 
Walbach  and  Ernst  came  to  the  conclusion  that  there  was  no  difference 
in  the  specificity  between  tuberculin  made  from  human  and  bovine 
bacilli  and  that  there  was  no  essential  difference  in  the  disease  processes 
caused  by  bacilli  from  these  sources.  Rau  believes  that  primary  intes- 
tinal tuberculosis  and  tabes  mesenterica  are  of  bovine  origin  and 
conveyed  by  milk.  Woodhead  believes  the  same.  Still  thinks  that 
tuberculosis  of  the  intestines  is  often  secondary,  caused  by  the  swallow- 
ing of  the  sputtUTi.  Behring  says  "The  milk  fed  to  infants  is  the  chief 
cause  of  consumption."  The  evidence  as  to  the  communicability  of 
bovine  tuberculosis  to  infants  is  so  conclusive  that  there  is  no  longer 
any  room  for  doubt.  The  only  point  in  question  is  as  to  the  comparative 
frequency  of  this  mode  of  infection.  This  source  of  infection  is 
no  doubt  very  frequent.  It  is  our  duty  to  guard  against  tubercular 
infection  in  every  possible  way  and  to  insist  on  milk  absolutely  free 
from  tubercle  bacilli  for  infant  feeding.  The  cows  should  be  tested 
with  tuberculin  and  those  which  react  positively  should  be  separated 
from  the  herd. 


ORTHOPEDICS. 

By  IRA  DEAN  LOREE,  M.D.,  Ann  Arbor,  Michigan. 

FIRST  ASSISTANT  IN  8URGBRT  IN  THE  UNIVBRSITT  OF  MICHIGAN. 


SOME  DEFORMITIES  ANQ  THEIR  PREVENTION. 

David  T.  Bowden,  M.  D.,  in  the  International  Journal  of  Surgery 
for  February,  1906.  Under  this  heading  he  describes  some  of  the  more 
common  congenital  deformities  of  the  lower  limbs,  their  causes,  and 
treatment;  also  some  of  the  acquired  forms  of  deformity,  in  different 
parts  of  the  body. 

The  valuable  part  of  the  article  must  be  summed  up  in  the  para- 
graphs devoted  to  the  responsibility  in  neglected  cases.  The  family 
physician  as  well  as  the  parents  must  be  educated  to  know  the  value 
of  early  intervention  in  all  cases  of  deformity,  especially  those  of 
congenital  origin.  Much  can  be  gained  even  in  those  cases  that  reach 
the  orthopedic  surgeon  late,  yet  complete  obliteration  of  the  marks  of 
neglect  is  often  impossible.  The  surgeon  must  be  given  the  best 
chance  and  this  necessitates  early  supervision  of  the  treatment.  The 
inconvenience  and  mental  suffering  of  these  patients  should  be  im- 
pressed upon  the  parents'  and  the  family  physician  should  be  in  a 
position  to  detect  these  abnormalities  at  once. 


INJURIES  OF  THE  EYE.  79 

OPHTHALMOLOGY. 

By  WALTER  ROBERT  PARKER.  B.  S.,  M.  D. 

rROFBSSOR  OP  OPHTHALMOLOOT  IM  TRB  UlflVBSSITY  OP   MICHIGAM. 


INJURIES  OF  THE  EYE  FOLLOWING  PARAFFIN  INJEC- 
TIONS IN  THE  NOSE. 

Professor  W.  Uhthoff,  of  Breslau  (Berliner  Klinische  Wachen- 
schrift,  December,  1905),  gives  the  following  reports  concerning  fre- 
quently practiced  injections  of  paraffin  in  the  nose. 

A  married  woman,  aged  forty-five,  exhibited  saddle-nose.  While 
there  was  a  history  of  traumatism,  examination  rendered  a  specific 
origin  not  improbable.  There  was  a  history  of  rheumatism.  The  heart 
was  normal.  In  all  there  had  been  three  injections  of  paraffin,  at  inter- 
vals of  eight  and  five  months,  for  the  treatment  of  the  nose  deformity. 
During  the  third  injection  the  patient  suddenly  noticed  the  left  eye 
becoming  blind.  There  was  no  pain,  but  some  lachrymation  and  sev- 
eral attacks  of  vertigo  were  experienced  on  her  way  home.  There  were 
no  material  inflammatory  manifestations,  but  there  was,  however,  on 
the  day  following  the  injection,  an  ophthalmoscopic  picture  of  embolism 
of  the  central  retinal  artery.  Vision  mV.  The  diagnosis  was  confirmed 
eight  days  later.  A  puncture  on  the  left  side  of  the  anterior  chamber, 
followed  by  massage  of  the  globe,  did  not  change  the  findings  of  the 
examination. 

Doctor  Uhthoff  thinks  there  is  no  doubt  that  a  small  particle  of  par- 
affin was  the  real  obstacle  that  beclouded  the  arteria  centralis  retinae, 
ind  it  must  be  assumed  that  the  foreign  body  passed  through  the  pul- 
monary circulation  prior  to  entering  the  artery.  Cases  of  this  kind 
must  be  regarded  as  exceedingly  rare  occurrences. 

An  analogous  case  is  that  reported  by  Hurd  and  Ward  Holden  ("A 
Case  of  Blindness  Following  a  Paraffin  Injection  Into  the  Nose,"  New 
York  Medical  Record,  July  11,  1903),  in  which,  after  the  third  injec- 
tion, loss  of  vision  likewise  occurred  in  the  corresponding  eye  under 
the  picture  of  embolism  of  the  central  retinal  artery.  In  explanation  of 
this  case  Hurd  and  Holden  are  inclined  to  presuppose  a  persistent  fora- 
men ovale  between  the  two  atria,  enabling  the  particle  to  pass  from 
the  right  atrium  into  the  left,  thus  obtaining  direct  access  to  the  arterial 
circulation. 

This  assumption  seems  to  Uhthoff  somewhat  arbitrary,  and  he  does 
not  claim  the  same  for  his  case.  The  most  probable  explanation,  accord- 
ing to  the  writer,  is  that  in  this  case  paraffin  found  its  way  during  injec- 
tion into  the  venous  system  and  after  passing  through  the  pulmonary 
circulation  entered  the  arterial  system  and  consequently  also  that  par- 
ticular arteria  centralis  retince, 

A  similar  case  was  reported  by  Moll  {Ann.  des  Mai,  d'Orielle  du 
Lar,  et  du  Phar,,  1902),  also  one  by  Rohmer  (Ann.  d'Occuliste,  1905). 

In  Leiser's  case,  which  was  reported  in  the  Deutsche  medicinische 


80  ORIGINAL  ABSTRACTS. 

IVochenschrift,  January,  1902,  amaurosis  of  the  left  eye  occurred  after 
the  third  paraffin  injection,  there  being  initial  collapse  and  continuous 
vomiting,  followed  by  inflammatory  turgescence  of  the  palpebrae,  les- 
sening of  motility,  and  symptoms  of  interocular  hemorrhage.  Leiser 
here  assumes  the  development  of  a  thrombosis  of  the  vena  ophthalmica. 

After  speaking  of  the  dangers  of  liquid  paraffin  as  compared  with 
semifluid,  and  mentioning  the  means  of  prevention  of  embolism  sug- 
gested by  Leiser,  the  author  reports  his  second  case. 

A  male,  aged  fifty-seven,  was  kicked  in  the  face  by  a  horse,  with 
the  resultant  deformity  of  saddle-nose.  Three  paraffin  injections  were 
made  in  1904,  and  the  result  was  satisfactory  until  the  end  of  February, 
1905.  About  that  time,  on  a  rather  warm  day,  patient  had  exerted  him- 
self to  the  extent  of  profuse  perspiration.  Suddenly  he  felt  an  itching 
and  pressure  in  both  eyes  which  he  proceeded  to  rub.  In  the  course 
of  a  few  hours  they  became  swollen,  and  lids  and  face  inflamed.  On  the 
following  day  he  was  unable  to  open  his  eyes.  Microscopic  examina- 
tion of  a  small  piece  of  skin  excised  from  the  strongly  swollen  palpebrae 
proved  that  the  inflammatory  proliferation  was  caused  by  penetration 
of  the  paraffin  into  the  eyelids.  For  several  months  patient  was 
unable  to  open  his  eyes.  In  order  to  enable  him  to  open  his  lids 
at  least  to  some  slight  extent  and  to  use  his  eyes,  it  was  necessary  to 
remove  the  hard,  tumor-like  proliferation  of  the  lids.  Microscopic 
examination  was  in  harmony  with  the  clinical  findings.  The  inflam- 
matory proliferations  are  occasionally  not  sharply  circumscribed  but 
coalesce  diffusely  into  the  surrounding  tissue.  Consequently  these  are 
not  sharply  circumscribed  and  encapsulated  paraffin  tumors,  but  infil- 
trations of  the  tissue  with  paraffin  particles  and  strong  interstitial 
inflammatory  proliferation.  In  fact  at  this  time  large  quantities  of  par- 
affin in  substance  are  no  longer  demonstrable  in  the  newly-formed 
tissue,  but  the  exceedingly  numerous  giant  cells  of  foreign  bodies  indi- 
cate that  diflFuse  paraffin  particles  in  the  tissue  have  decided  the  point 
of  origination  for  the  new  formation  of  the  strong  inflammatory  tissue. 


OTOLOGY. 

By  R.  bishop  CANFIELD,  A.  B..  M.  D..  Ann  Arbor.  Michigan. 

PROPBSSOR  OP  OTOLARYNGOXX>GY  IN  THB  UNIVERSITY  OP  MICHIGAN. 
AND 

WILLIAM  ROBINSON  LYMAN,  A.  B.,  M.  D.,  Ann  Arbor,  Michigan. 

DBMOMSTRATOR  OP  OTOLARYNGOLOGY  IN  THB  UNIVBRSITY  OP  MICHIGAN. 


ACUTE  BILATERAL   MIDDLE  EAR   SUPPURATION   FOL- 
LOWING AN  INTRANASAL  OPERATION,  AND 
RESULTING  IN  DEATH  FROM  PYEMIA. 
Otto  J.  Stein,  M.  D.,  in  The  Laryngoscope,  Volume  XVI,  Number 
I.     The  salient  points  in  this  case  are: 

( I )  An  acute  suppurative  process  in  both  ears,  following  an  intra- 
nasal operation. 


MIDDLE  EAR  SUPPURATION.  81 

I  (2)  Absence  of  all  pain  or  tenderness  in  or  about  the  ears  subse- 

j  quent  to  the  incision  of  the  drum  membranes  on  the  third  and  fifth  days 

j  respectively. 

j  (3)  A  profuse  aural  discharge,  showing  only  diplococci,  continu- 

ing for  sixteen  days. 

(4)  A  most  profound  deafness. 

(5)  The  maintenance  of  a  high  temperature  for  sixteen  days,  with 
no  decided  changes  excepting  one  complete  remission  on  the  seven- 
teenth day. 

(6)  Absence  of  rigors  and  perspiration. 
^                                         (7)  Pus  in  the  urine. 

(8)  Diarrhea. 

(9)  Metastasis  in  the  knee-joint  and  side  of  the  thorax. 

( 10)  A  complicating  angina  of  the  soft  palate  and  arches,  with  the 
membrane  showing  diplococci  catarrhalis  infection,  the  same  as  found 
in  the  ears. 

The  patient  was  a  female,  forty-one  years  old,  thin  and  weak,  but 
complaining  of  no  particular  ailment.  Two  days  after  removal  of  the 
posterior  end  of  the  left  inferior  turbinate  she  suffered  from  earache  on 
the  right  side.  The  membrane  was  incised  on  the  third  day.  On  the 
fourth  day  the  left  ear  ached  and  the  membrane  was  incised.  After  the 
incisions  all  pain  disappeared  and  both  ears  discharged  freely.  The 
temperature  from  the  first  remained  high  with  no  remissions.  Doctor 
Stein  saw  the  case  on  the  thirteenth  day  of  the  first  ear  symptoms,  at 
which  time  the  temperature  was  102**,  pulse  120,  regular  and  full,  res- 
piration 28.  Patient  complained  of  no  discomfort  but  deafness  was  such 
that  one  had  to  shout  into  her  ears,  and  there  was  no  history  of  deaf- 
ness previous  to  the  operation.  She  was  nauseated  and  had  vomited 
that  morning.  There  was  present  a  mild  diarrhea  but  no  abdominal 
tenderness.  Chest  examination  was  negative.  The  secretion  from  the 
ears  ran  into  the  throat  and  there  was  a  membrane  over  the  soft  palate 
and  uvula  which  was  not  at  all  painful.  Pus  escaped  freely  from  the 
large  openings  in  the  membranes.  Exposed  bone  was  detected  in  the 
middle  ear  of  the  left  side.  No  mastoid  tenderness.  Temperature 
,  103.6**,  pulse  125.    Blood  examination  gave  4,000,000  red,  15,000  white, 

hemoglobin  eighty  per  cent.    Ear  examination  was  negative. 

On  the  sixteenth  day  the  patient  complained  of  pain  about  the  right 
j  knee.    The  urine  examination  on  the  following  day  showed  pus,  albu- 

I  min,  streptococci  and  staphylococci.     The  temperature  dropped  to  96.4°. 

The  left  mastoid  was  opened;  the  bone  was  hard  and  white,  showing 
no  signs  of  necrosis.  The  sigmoid  sinus  was  exposed  throughout  its 
entire  length  and  found  apparently  healthy ;  the  tip  of  the  mastoid  was 
removed ;  and  cells  far  into  the  zygoma  taken  away.  The  only  evidence 
of  inflammation  was  in  the  antrum  and  middle  ear  where  the  membrane 
was  thick  and  covered  with  granulations.  No  openings  could  be  found 
into  the  cranial  fossa. 

The  following  day  the  patient  was,  at  times,  in  a  comatose  state  and 


ORIGINAL  ABSTRACTS. 


j  the  right  mastoid  was  opened  with  the  hope  of  finding  some  avenue  of 

j  venous  infection.    A  condition  similar  to  the  left  was  found,  the  sinus 

I  was  exposed  and  found  apparently  normal,  so  it  was  not  opened.    The 

I  patient  was  in  her  rocmi  an  hour  after  leaving  it  and  her  condition 

improved  so  that  she  recognized  her  family,  but  the  coma  gradually 
deepened  and  she  died  ten  hours  later.  No  autopsy  could  be  obtained. 
The  most  common  avenue  for  septic  material  to  gain  entrance  to  the 
circulation  from  the  middle  ear  and  antrum  is  through  the  large  sinuses. 
This  could  not  be  discovered.  Septic  material  has  gained  entrance  to 
the  circulation  through  the  small  veins  and  this  has  occurred  as  a  result 
of  osteomyelitis  of  the  mastoid,  and  the  question  arises  whether  suffi- 
cient absorption  could  have  taken  place  from  the  middle  ears  and  antra 
to  have  caused  the  fatal  result.  On  account  of  the  sudden  marked  deaf- 
ness the  extension  of  the  disease  through  the  labyrinth  must  be  consid- 
ered. This  might  have  taken  place  through  the  internal  meatus,  or 
along  the  aquaeductus  vestibuli  or  aquaeductus  cochlae,  or  along  the 
veins  leaving  the  inner  ear.  r.  b.  c. 


LARYNGOLOGY. 

By  WILLIS  SIDNEY  ANDERSON,  M.  D.,  Detroit.  Michigan. 

ASSISTANT  TO  THB  CHAIR  OP  LAKTNGOLOGT  IN  THB  DBTKOIT  COLLS6B  OP  MBDICINB 


ORBITAL  AND  MENINGEAL  INFECTION  FROM  THE 
ETHMOID  CELLS. 

James  F.  McCaw  (American  Journal  of  the  Medical  Sciences, 
August,  1905)  reports  a  case  in  a  man,  forty  years  of  age,  who  had 
had  catarrh  and  nasal  obstruction  for  years.  Severe  cerebral  symptoms 
developed  leading  to  the  patient's  death. 

Postmortem  showed  that  the  infection  originated  in  the  ethmoid 
cells,  broke  through  the  os  planum,  stripping  the  periosteum  from  the 
roof  of  the  orbit,  extending  outward  and  downward  to  the  external 
angular  process  of  the  temporal  bone,  and  there  passed  out  to  form  the 
subperiosteal  collection  of  pus  described  in  the  paper.  These  cases  are 
rare  but  nevertheless  cerebral  infection  from  the  nose  takes  place  often 
enough  to  warrant  more  care  on  the  part  of  practitioners. 


THE  TREATMENT  OF  EMPYEMATA  OF  THE  MAXILLARY 
SINUS  THROUGH  THE  NOSE. 
George  L.  Richards  (Journal  of  the  American  Medical  Association, 
September  16,  1905),  divides  etiologically  these  cases  into  those  of 
nasal  and  dental  origin.  The  author  advises  the  treatment  of  the  sinus 
by  the  nasal  route.  If  of  dental  origin  extract  the  tooth,  treat  the  infec- 
tion, and  allow  the  wound  to  close.  When  not  of  dental  origin  puncture 
high  underneath  the  inferior  turbinal  and  wash  out  the  antrum.  If  this 
does  not  suffice  enlarge  the  opening  sufficiently  so  that  it  will  remain 
open  during  the  required  time  of  treatment.  The  antrum  can  then  be 
curetted  or  packed  with  gauze  as  the  case  requires. 


SPASTIC  CONSTIPATION. 

PROCTOLOGY. 

By  LOUIS  JACOB  HIRSCHMAN,  M.  D.,  Detroit,  Michigan. 

CUMXCAL  PKOFUSOm  OP  PKOCTOLOGT  IH  THB  OmtOtT  COLLBGX  OP  MBOICINB. 


LOCKING  THE  BOWELS  FOR  FROM  TEN  DAYS  TO 
TWO  WEEKS. 

•Howard  A.  Kelly,  in  the  February,  1906,  number  of  Surgery, 
Gynecology,  and  Obstetrics,  concludes,  after  discussing  a  series  of 
twelve  cases  of  plastic  work  around  the  rectum,  that  an  enforced 
obstipation  lasting  from  eight  to  fifteen  days  is  of  great  value  in  the 
management  of  these  cases  after  operation.  His  patients  are  put  on 
a  diet  of  egg-albumin  and  water ;  this  being  practically  all  assimilated, 
and  leaving  no  residue  in  the  bowel.  The  first  twenty-four  hours,  the 
patient  receives  no  food  whatever;  on  the  second  day  one  and  a  half 
ounces  of  albumin  in  water  at  two  feedings;  on  the  third  day  three 
ounces  divided  into  fiyf  or  six  feedings  about  three  hours  ap>art;  on 
the  fourth  day  three  and  a  half  ounces  in  the  same  manner;  fifth  day 
and  daily  till  the  tenth  or  fifteenth  day,  six  ounces  per  diem.  The 
bowel  is  moved  at  the  end  of  the  period  by  giving  a  half  ounce  of 
licorice  powder,  followed  in  some  cases  by  an  oil  enema,  and  perhaps 
the  next  morning  by  a  half  ounce  of  salts.  One  of  the  most  important 
factors  in  securing  the  first  evacuation  is  to^  have  the  patient  lying 
in  the  Sims  position,  so  as  to  obviate  straining.  Scybala  will  not 
form  even  after  this  long  period  of  intestinal  stasis,  if  milk  is  eliminated 
from  the  diet,  and  a  perfectly  soft  stool  is  procured  from  the  albumin 
diet. 


"SPASTIC  CONSTIPATION. 

Dudley  Roberts,  in  the  Brooklyn  Medical  Journal,  for  March, 
1906,  claims  that  this  form,  in  which  the  retention  of  feces  is  due  to  a 
spastic  contracture  of  a  part,  or  the  whole  of  the  lower  bowel,  often 
supervenes  upon  a  long-standing  atonic  constipation.  He  quotes  sev- 
eral authorities  to  support  his  contention  that  as  high  as  twenty-five 
per  cent  of  all  cases  of  habitual  constipation  are  of  this  variety. 
Usually  this  spastic  condition  is  due  to  neurasthenia,  hypochondria,  or 
hysteria,  or  it  may  be  a  reflex  from  disease  of  other  organs.  The  stools 
are  not  hard,  are  of  small  caliber,  or  of  a  "sheep-dung"  shape,  and  are 
passed  mainly  by  the  pressure  of  the  diaphragm  and  abdominal  muscles. 
The  large  balls  of  hard  fecal  matter,  so  common  in  atonic  constipation, 
are  absent  in  this  condition.  Palpation  reveals  some  part  or  even  the 
entire  colon  contracted  to  the  size  of  the  index  finger,  and  it  can  be 
rolled  under  the  palpating  hand. 

The  treatment  of  this  condition  is  the  treatment  of  the  underlying 
neurotic  condition.  These  patients  are  usually  poorly  nourished  and 
undeveloped.  Suggestion  is  of  value  on  those  patients  who  are  con- 
tinually worrying  about  the  action  of  their  bowels.    It  is  stated  that 


84  ORIGINAL  ABSTRACTS. 

the  coarse  vegetables  and  fruits,  so  valuable  in  atonic  constipation, 
are  strong  irritants  to  the  mucosa  in  this  condition.  Fats  are  well 
borne,  as  well  as  sugars  and  honey.  Warm  sitz  baths  and  abdominal 
compresses  are  of  value,  while  cold  applications  and  massage  are  con- 
traindicated.  All  cathartics  are  discarded,  as  the  intestine  has  an  over- 
plus of  contractile  force.  Hyoscyamus  and  belladonna  in  suppositories 
are.of  distinct  value.  Rectal  and  oral  exhibition  of  olive  oil  is  one  of 
the  best  forms  of  treatment.  The  amount  given  by  mouth  is  only 
limited  by  the  patient's  ability  to  digest  it,  while  the  enemata  vary  from 
five  to  fifteen  ounces,  warmed  to  99°  Fahrenheit  and  given  at  night  and 
retained  till  morning.  This  is  done  daily  for  a  week  and  then  gradu- 
ally "tapered  off."  Bromides  and  chloral  are  given  by  mouth  in  some 
cases,  and  spasm  of  the  sphincter  is  relieved  by  forcible  dilatation  under 
gas  or  ether  anesthesia.  The  cure  of  the  condition  may  require  months 
of  treatment. 


NEUROLOGY. 

By  DAVID  INGLIS,  M.  D..  Detroit,  Michigan. 
pROFissom  OP  Nsmvous  and  mbntal  dissasbs  in  thb  pbtroit  collbgs  op  mbdicinb. 

AND 

IRWIN  HOFFMAN  NEFF,  M.  D.,  Pontiac,  Michigan. 

ASSISTANT  PHYSICIAN  AT  THB  BASTBKN  MICHIGAN  ASYLUM. 


BRAIN  TUMORS:  A  STUDY  OF  CLINICAL  AND  POST- 
MORTEM RECORDS  BEARING  ON  THEIR  OPERA- 

BILITY  AND  THEIR  SYMPTOMATOLOGY. 
G.  L.  Walton  and  W.  E.  Paul  (Journal  of  Nervous  and  Mental 
Diseases,  August,  1905)  contribute  a  paper  based  on  a  study  of  autopsy 
records  and  specimens  of  two  hundred  twenty-one  cases  of  brain  tumor. 
The  number  of  operative  cases  from  the  author's  point  of  view  was 
three  per  cent.  The  clinical  features  considered  are:  convulsions, 
headache  and  vomiting,  mental  symptoms,  condition  of  pupils,  and 
reflexes.  As  the  writers  have  been  concerned  particularly  in  the  inves- 
tigation of  various  reflexes,  their  interpretation  of  the  findings  of  the 
reflexes  is  of  considerable  import.  They  state  that  there  is  need  for  an 
enormous  amount  of  detailed  labor  before  an  exact  idea  can  be  reached 
of  the  locations  of  the  mechanism  concerned  in  the  various-  reflexes  and 
their  interpretations.  Considerable  variation  was  observed  in  the  con- 
dition of  both  the  deep  and  superficial  reflexes  in  brain  tumors;  and 
although,  as  they  say,  their  findings  were  insufficient,  they  believe  that 
even  the  meager  findings  they  noted,  suggest  that  it  is  worth  while  to 
carry  on  the  study  of  the  brain  as  an  important  integral  part  of  the 
reflex  mechanism.  Concerning  the  knee-jerk,  they  believe  that  the  fact 
is,  however,  established  that  the  knee-jerk  not  infrequently  disappears 
in  brain  tumor ;  and  while  confessing  their  inability  to  critically  analyze 
all  the  findings  which  they  recorded,  they  submit  that  they  are  not 
easily  recognizable  with  any  theory  which  accepts  the  spine  as  the  sole 


THE  SECRET  NOSTRUM  EVIL.  85 

seat  of  the  reflex  arcs.  The  authors  conclude  the  paper  with  the  fol- 
lowing suggestion :  "The  facts  here  collected  are  presented  merely  as 
stiggestivc,  not  as  demonstrative  or  as  representing  final  results.  The 
main  object  in  this  branch  of  the  communication  is  to  direct  attention 
to  the  importance  of  more  complete  and  careful  observaticwis  of  the 
locations  and  the  periods  in  which  central  growths  affect  the  reflexes, 

with  a  view  to  furthering  the  final  analysis  of  the  cerebral  reflex  \ 

mechanism/'  i.  h.  n.  ' 


THERAPEUTICS. 

By  DELOS  LEONARD  PARKER,  Ph.  B.,  M.  D.,  Detroit,  Michigan. 

LBCnimSB  OM  MATBIIIA  MBDICA  IN  TMB  DBTKOIT  COLLSOB  OV  MBDICIMB. 


THE  SECRET  NOSTRUM  EVIL. 

For  some  time  unmistakable  signs  have  appeared  in  medical 
journals  and  medical  conversations  that  go  to  show  that  the  medical 
profession  is  fast  becoming  wearied  with  unscientiflc  therapeutics. 
No  more  telling  sign  of  this  kind  has  ccwne  to  the  notice  of  the  profes- 
sion at  large  than  that  exhibited  by  Frank  Billings,  M.  D.,  of  Chicago, 
in  a  paper  entitled  "The  Secret  Nostrum  Evil,"  read  before  the 
American  Medical  Association,  July,  1905,  and  published  in  the 
December  2,  1905,  number  of  the  association  journal. 

The  doctor  begins  by  saying  that  "proprietary  medicine"  does  not 
necessarily  stamp  a  preparation  or  remedy  as  a  nostrum.  Some  prop- 
prietary  medicines  are  patented,  a  process  that  causes  their  owners 
to  file  at  the  patent  office  their  formulas  and  their  mode  of  prepara- 
tion. For  a  small  fee  any  person  can  get  from  the  patent  office  a  copy 
of  the  information  bearing  on  the  remedies  that  have  been  recorded 
there.  Whether  or  not  the  patented  remedy  or  remedies  are  prepared 
in  conformity  with  the  information  furnished  the  patent  office  is 
another  story.  Whether  or  not  a  patented  remedy  contains  the  same 
ingredients  one  year  that  it  does  another  is  also  another  story.  What- 
ever the  actual  facts,  however,  the  profession  could  easily  get  on 
without  patented  remedies  and  fare  better  with  older  and  simpler 
combinations. 

The  so-called  copyright  preparations  do  not  differ  in  any  essential 
particular  from  "patent  medicines."  Both  are  protected  by  copyright 
for  an  indefinite  period,  and  both,  as  a  rule,  are  mixtures  of  several 
ingredients,  prepared  with  the  idear  not  that  they  will  correct  disturbed 
functions  of  the  body,  but  that  they  will  sell  and  bring  money  to  the 
coffers  of  somebody.  Doctor  Billings  quotes  Doctor  H.  C.  Wood,  Jr., 
as  follows: 

"A  much  more  elusive  and  therefore  dangerous  evil  lurks  in  the 
class  of  mixtures  which  attempt  to  cloak  their  secrecy  with  a  deceptive 
show  of  frankness.  I  think  you  will  grant  that  the  physician  is  rarely 
justified  in  the  use  of  remedies  concerning  which  he  has  no  knowledge, 
and  I  maintain  that  the  publication  by  a  drug  firm,  of  whose  integrity 


g6  ORIGINAL  ABSTRACTS. 

the  physician  is  absolutely  ignorant,  of  a  professed  list  of  ingredients 
of  some  mixture  is  not  sufficient  knowledge  to  parilon  or  to  warrant 
the  uses  of  that  remedy.  In  the  first  place,  if  the  published  formula 
be  correct,  it  is  not  enough  to  know  simply  the  composition  of  a  mix- 
ture, the  exact  quantities  must  also  be  known ;  there  is  a  vast  difference 
between  the  eflfects  of  one  grain  and  of  one  hundred  grains  of  opium. 
Moreover,  there  is  no  means  of  knowing  that  the  formula  is  a  true 
one,  for  many  of  these  corporations  do  not  hesitate  to  pervert  the 
truth." 

Preparations  of  reliable  manufacturing  chemists,  made  up  of 
known  ingredients,  and  recommended  to  the  profession  simply  for 
their  palatability  or  convenience  of  form  are  not  included  in  the  list 
of  preparations  to  be  condemned. 

Doctor  Billings  closes  his  paper  as  follows : 

"What  is  the  cause  of  the  nostrum  evil  ?    There  are  several. 

"(i)  Pharmacology  and  therapeutics  are  neglected  relatively  by 
many  of  our  medical  schools.  Anatomy,  physiology,  pathology,  diag- 
nosis, et  cetera,  are  emphhasized  and  too  often  the  usefulness  and  limit- 
ations of  drugs  are  neglected.  Too  frequently  drug  nihilism  is  taught. 
If  the  student  were  fully  taught  the  physiologic  action  of  drugs,  the 
art  of  prescribing,  preferably  single  remedies  or  in  simple  combination, 
using  if  he  desires  the  pharmacopeial  preparations  prepared  by  reliable 
manufacturing  pharmacists,  and  at  the  same  time  if  he  were  taught 
when  not  to  rely  on  drugs,  but  frankly  to  prescribe  for  his  patient  a 
course  of  hygienic  measures  which  alone  would  accomplish  all  that 
would  be  required,  he  would  not  be  the  willing  dupe  of  the  nostrxun 
vendor,  as  he  now  is. 

"(2)  The  reput^ible  manufacturing  pharmacists  deserve  great 
credit  for  the  improvement  they  have  made  in  pharmaceutical  prod- 
ucts. They  have  afforded  us  official  preparation^  in  the  form  of  pills, 
tablets,  syrups,  tinctures,  extracts,  et  cetera,  which  are  elegant  in 
appearance,  often  palatable  and  usually  potent.  For  this  advance  in 
pharmacy,  a  distinct  credit  to  our  country,  we  owe  them  our  thanks. 
Unfortunately,  many  of  them  have  not  stopped  at  this  point,  but  have 
manufactured  their  own  special  mixtures  which  are  just  as  objection- 
able as  the  products  of  the  special  manufacturers.  They,  too,  have 
been  active  with  their  agents  in  visiting  physicians  and  in  distributing 
'literature.'  This  encourages  drug-giving  in  specific  mixtures  for 
special  symptoms,  and  is  wrong.  With  one  hand  they  do  good  work, 
with  the  other  much  evil  is  done. 

"(3)  The  nostrum  makers  at  first  copied  the  methods  of  the  reli- 
able manufacturing  chemists,  in  exploiting  their  products,  but  they 
have  gone  a  step  farther  and  have  reached  a  point  where  one  may  say 
that  they  have  subsidized  the  medical  press.  I  know  I  am  on  dan- 
gerous ground  when  I  make  this  statement,  but  right  here  is  the  chief 
cause — and  the  remedy.  How  many  of  our  so-called  medical  journals 
are  subsidized  by  medicine  manufacturers  I  do  not  know,  but  all  physi- 
cians know  as  well  as  I  that  there  are  many,  and  I  do  not  refer  to  the 


MILK  PRESERVATION.  87 

so-cailed  house  organs.  I  unhesitatingly  affirm  that  one-half  of  the 
medical  journals  of  the  country. would  be  out  of  existence  if  it  were 
not  for  the  nostrum  advertisements.  Under  the  circumstances,  there- 
fore, can  we  expect  these  journals  to  say  anything?  Need  we  be  sur- 
prised that  scarcely  a  journal  published  the  official  report  regarding 
the  acetanilid  mixtures,  when  the  preparations  hit  were  the  best  paying 
advertisements  in  the  country? 

"What  is  the  remedy?  Publicity.  The  enlightenment  of  the  pro- 
fession. The  truth  regarding  not  only  what  the  preparations  contain, 
but  who  makes  them.  Certainly  no  honest  manufacturer  will  object 
to  this  last  proposition,  and  no  honest  physician  will  put  up  with  less 
than  the  former. 

"The  Council  on  Pharmacy  and  Chemistry  has  been  created  to 
investigate  the  nonofficial  preparations,  to  find  out  the  truth  about 
them,  and  to  publish  its  findings.  It  is  not  necessary  to  repeat  here 
the  results  of  the  work  already  done  by  this  body.  All  physicians 
have  read,  or  may  read  all  about  it.  In  my  opinion  there  has  been  no 
movement  undertaken  by  the  American  Medical  Association  that  will 
be  so  far  reaching  as  this  one  to  rid  us  of  the  blight  of  the  nostrum  evil. 
For  the  first  time,  we  see  the  possibility  of  the  elimination  of  a  part, 
at  least,  of  this  curse  to  American  medicine.  It  is  the  first  practical 
solution  offered  of  a  most  difficult  problem." 


EDITORIAL  COMMENT. 


A  QUICK  MEANS  OF  PRESERVING  MILK. 
The  fertility  of  milk  as  a  culture  medium  for  bacteria,  as  evidenced 
by  the  rapidity  with  which  organisms  increase  in  the  liquid  and  the 
consequent  putrefaction,  has  prompted  many  efforts  by  scientists  to 
discover  some  ready  means  for  preserving  this  excellent  nutritive 
article  without  altering  the  character  of  its  composition.  Experiments 
have  demonstrated  that  in  the  short  space  of  one  hour  one  cubic  centi- 
meter of  milk  may  provide  for  the  generation  of  over  six  thousand 
organisms,  and  that  after  the  lapse  of  twenty-four  hours  this  growth 
may  increase  to  the  magnitudinous  proportions  of  about  eleven  million. 
These  observations  were  made  with  milk  procured  under  ideal  con- 
ditions, and  obviously  the  number  of  microbes  would  be  decidedly 
greater  were  the  milk  secured  from  an  unhygienic  dairy.  Refriger- 
ation affords  an  admirable  means  of  checking  the  growth  of  bacteria, 
but  since  this  process  is  not  always  convenient  its  impracticability  for 
general  purposes  is  apparent,  and  indeed  the  same  may  be  said  of  the 
various  other  preservative  measures  known  to  science. 

*     *     * 

It   therefore   seems   appropriate   to  chronicle   a   relatively   simple 
method  employed  with  great  success  by  Renard,  a  Frenchman,  which. 


88  EDITORIAL  COMMENT. 

while  not  intended  as  a  preservative  for  long  periods,  has  given  prime 
results  in  checking  bacterial  growth  for  from  two  to  three  days,  or 
even  longer  time.  An  interesting  feature  in  the  preservation  is  that 
no  antiseptics,  such  as  formol,  salicylic  acid,  or  borax,  are  employed, 
the  mere  admixture  of  the  milk  with  oxygenized  water  sufficing  to 
retard  the  growth  of  organisms  through  decomposition  of  the  water, 
the  milk  being  unaffected  and  absolutely  pure  and  sweet  at  the  termi- 
nation of  the  process.  In  experiments  recently  conducted  at  Rouen, 
the  investigator  obtained  excellent  results  by  pouring  a  two-per-cent 
solution  of  water,  oxygenized  at  twelve  volumes,  into  the  milk.  The 
results  already  achieved  indicate  the  unadvisability  of.  employing  the 
water  in  stronger  than  three-per-cent  solution,  since  the  decomposition 
of  a  more  powerful  solution  in  the  milk  may  lead  to  undesirable  out- 
come. After  treatment  with  a  three-per-cent  solution,  milk  was  pre- 
served at  a  temperature  of  1 1  °  centigrade,  without  the  slightest  trace 
of  acidity  for  ninety-five  hours,  while  preservation  could  be  maintained 
for  only  thirty-two  hours  at  a  temperature  of  twenty  degrees. 

*  lit  3|C 

That  milk  preserved  by  the  above  method  is  absolutely  pure  was 
demonstrated  in  one  of  the  dispensaries  at  Rouen,  where  fifty-seven 
infants  were  fed  on  the  product  with  uniformly  good  effect.  The 
results  obtained  with  boiled  milk  were  not  favorable,  since  the  oxygen- 
ized water  forms  certain  combinations  with  the  elements  of  the  milk 
which  have  undergone  change  in  boiling.  Experiments  conducted  by 
Nicolle  and  Duclaux  upon  the  comma  bacillus,  the  bacillus  of  cholera, 
the  bacillus  coli,  and  certain  pus-producing  organisms  demonstrate 
that  the  oxygenized  water  process  does  not  destroy  pathogenic  bacteria 
with  any  degree  of  certainty.  The  question  may  be  asked,  then,  why 
is  not  Pasteurization  a  more  acceptable  method,  since  it  insures  the 
destruction  of  all  organisms,  with  the  possible  exception  of  the  tubercle 
bacillus?  So  far  as  the  destruction  of  bacteria  is  concerned  the 
Pasteur  method  is  ideal,  but  it  does  not  insure  preservation,  and  the 
milk,  after  being  subjected  thereto,  is  devoid  of  many  of  its  nutritive 
properties. 


ANNOTATIONS, 

STUDIES  IN  SIMIAN  VERNACULAR. 
Professor  Garner,  the  eminent  scientist,  who  is  the  discoverer  of 
the  monkey  language,  is  to  undertake  a  second  expedition  into  the 
wilds  of  Western  Africa  to  further  his  studies  in  simian  vernacular. 
The  professor  carries  with  him  a  green  cage  in  which,  while  making 
observations,  he  is  secure  from  the  ravages  of  the  serpent  and  ferocious 
beasts  of  the  jungle.  By  means  of  intricate  apparatus  he  was  enabled, 
on  a  former  expedition,  to  record  certain  inarticulate  sounds  from  afar, 
which  observation  taught  him  to  decipher.       By  means  of  definite 


OBSERVATIONS  IN  ANIMAL  OPTICS.  89 

articulation  he  was  able  to  put  to  flight  an  entire  nKmkey  horde,  and 
with  equal  dexterity  could  assemble  the  quadrumana  by  imitating  their 
expression  for  "all  is  well."  He  learned  to  recognize  their  sound  for 
food  and  water  and  for  many  other  things,  and  could  in  course  of 
time  converse,  so  to  speak,  with  the  tribe.  The  contemplated  expe- 
dition will  doubtless  be  more  fruitful  in  its  results,  however,  as  Gamer 
will  take  with  him  the  most  perfect  phonographs  ever  produced,  that 
record  may  be  made  of  the  language  of  the  wild. 


THEORIES  APPERTAINING  TO  APPENDICITIS. 

Mahler,  in  a  German  periodical,  discusses  appendicitis  and  theo- 
rizes on  the  factors  leading  to  its  causation.  The  French  theory  that 
particles  of  porcelain  from  cooking  utensils  are  responsible  for  the 
affection  must  be  abandoned,  since  in  one  thousand  operations  Krem- 
mer  found  no  trace  of  such  substance  in  the  appendix.  According  to 
Mahler,  heredity  undoubtedly  plays  an  important  role  in  the  causation 
of  the  disease,  as  is  evidenced  by  repeated  attacks  in  the  same  family. 
This  author  ventures  the  suggestion,  however,  that  meat  may  be  a 
provocative  factor,  and  cites  the  prevelance  of  appendicitis  in  America, 
England,  and  the  city  of  Hamburg,  where  meat  is  the  chief  food  staple, 
in  support  of  this  idea.  The  fact  that  appendicial  attacks  occur  more 
generally  among  people  of  wealth  in  Europe  is  further  empharfzed,  as 
the  economic-  conditions  existing  abroad  preclude  the  poorer  classes 
from  meat  indulgence. 

OBSERVATIONS  IN  ANIMAL  OPTICS. 
Doctor  Lindsay  Johnson,  the  English  ophthalmologist,  who  has 
been  studying  the  optic  apparatus  of  various  animals,  has  made  some 
valuable  discoveries  which,  according  to  Lankester,  the  noted  zoologist, 
will  require  the  entire  rearrangement  of  one  section  of  zoology.  That 
man  bears  a  close  relationship  to  the  lower  forms  is  reiterated  in 
Johnson's  findings.  The  similarity  of  the  eye  of  man  and  that  of  the 
anthropoid  apes,  according  to  this  investigator,  is  suggestive  of  the 
Darwinian  theory.  Each  is  equipped  with  a  highly  complex  arterial 
and  venous  system,  and  parallel  vision  is  characteristic  of  both.  The 
observations  disclose  the  probability  that  the  canine  family  is  a  product 
of  two  ancestries,  since  in  the  dog  may  be  found  both  the  round-  and 
oval-eyed  types.  The  first  species  is  undoubtedly  the  result  of  an 
admixture  of  hyena  blood.  The  eye  of  animals  exposed  to  the  chase — 
the  squirrel,  hare,  et  cetera — is  so  situated  that  the  vision  is  unlimited, 
the  animal  being  able  to  see  in  all  directions,  without  altering  position. 
The  fact  was  likewise  observed  that  all  rodents  squint,  but  the  signifi- 
cance of  this  peculiarity  remains  unascertained.  The  parallel  vision  is 
especially  typical  of  the  higher  forms,  and  the  lower  in  the  scale  of 
development  the  animal  is  classified  the  less  liability  is  there  to  this 
optical  adjustment.     Perhaps  the  most  interesting  feature  of  Johnson's 


go  EDITORIAL  COMMENT. 

research  is  his  theory  as  to  the  nature  of  the  corpus  nigcr  in  the  eye  of 
the  horse,  which  has  caused  so  much  speculation  among  scientists. 
This  structure  is  found  in  nearly  all  tropical  animals — the  camel,  onegar, 
and  antelope — and  fulfills  the  function  of  protecting  the  eye  from  the 
sun's  rays.  Its  presence  in  equinae  affords  a  possible  means  of  tracing 
the  ancestry  of  the  horse. 


CONTEMPORARY. 


PHYSICIANS  AND  PHILOSOPHERS. 

[PROPISSOll  CHAHLBS  WILLIAM  SUPER,  OP  OHIO  UNXVBRSITT,  IN  POPULAH  SCIBNCB  MONTHLY.] 

{C^mtinutd  from  page  44.) 

Apropos  of  the  intimate  relationship  existing  between  the  stu-^.v 
of  nature  and  the  healing  art,  we  find  that  the  Romans  as  early  as  the 
time  of  Cicero  called  a  natural  philosopher  physicus,  while  the  science 
itself  was  called  physica,  both  words  having  been  borrowed  from  the 
Greek  physikos,  that  which  pertains  to  nature,  from  physis,  nature, 
in  the  somewhat  restricted  sense  of  the  term  as  used  in  antiquity.  But 
in  medieval  Latin  physica  had  become  the  equivalent  of  mededna  and 
physicus  that  of  medicus.  In  the  older  English,  physic  means  both 
natural  philosophy,  the  modern  physics,  and  the  medical  art  as  well  as 
drugs.  The  restricted  signification  'to  purge*  and  'a  purge'  is  com- 
paratively recent. 

Shakespeare  uses  both  doctor  and  physician,  the  former  generally  in 
the  sense  of  teacher.  Doctor  also  occurs  in  Middle  English  and  later 
Chaucer  speaks  of  a  'doctour  of  Phisik.'  In  classical  Latin  the  term 
doctor  means  teacher,  a  sense  in  which  it  is  used  by  Cicero,  Horace 
and  others.  It  had  no  connection  with  medicine.  In  modern  French 
physicien  means  one  who  occupies  himself  with  physics,  but  in  the 
older  language  it  had  the  signification  of  the  English  physician.  The 
French  medecin,  physician,  is  evidently  from  the  Latin  medicinus,  a 
derivative  from  medicus,  while  our  medicine,  a  remedial  drug,  is  from 
the  same  word  in  the  feminine  gender.  In  German  the  connection 
with  the  English  physician  is  preserved  by  Physikus  alone,  a  term  used 
to  designate  an  official  whose  functions  correspond  in  the  main  with 
our  health-officer.  Here  too  the  term  Doktor  has  long  since  usurped 
the  more  specific  Artst,  and  Doktorei  is  occasionally  used  for  medicine, 
'doctor's  stuff.'  The  Gothic  word  lekeis,  which  is  the  Anglo-Saxon 
laece  and  the  English  'leech'  has  nothing  in  common  with  either 
except  the  meaning.  This  term  doctor  again  brings  to  the  physician 
the  same  title  that  ib  borne  by  the  scholar.  Although  it  is  given  in 
several  departments  such  as  law,  theology,  music,  philosophy,  and  so 
on,  to  the  common  man  both  in  German  and  in  English  countries  the 
doctor  represents  only  the  physician.  This  is  explained  by  the  fact 
that  in  most  communities  the  only  man  or  men  bearing  the  title  were 
physicians.     Of  late  years,  however,  especially  in  the  United  States, 


PHYSICIANS   AND  PHILOSOPHERS.  91 

doctors  of  divinity  have  becwne  so  common,  not  to  mention  other 
doctors,  that  the  designation  has  reached  the  stage  of  painful  uncer- 
tainty. What  it  now  represents  can  only  be  determined  by  an  investi- 
gation of  each  individual  on  whom  it  has  been  conferred. 

No  more  convincing  testimony  to  the  small  progress  made  in  the 
healing  art  from  the  earliest  times  until  a  little  more  than  a  century 
ago  need  be  asked  for  than  is  offered  by  a  comparison  of  the  average 
length  of  human  life  as  given  by  Herodotus  and  that  currently 
accepted  until  quite  recently — three  generations  to  a  century.  In  fact 
most  life  insurance  associations  have  not  yet  learned  that  this  average 
is  above  forty  years.  Anatomy  had  made  great  progress  and  the  struc- 
ture of  the  body  was  minutely  known,  but  until  the  germ  theory  of 
disease  and  antisepsis  were  established,  therapeutics  was  largely  a 
matter  of  tradition  and  routine;  of  empiricism  and  individual  skill. 
When  one  reads  of  the  incessant  wars  that  kept  a  portion  of  the  male 
inhabitants  constantly  occupied  in  military  enterprises,  directly  or 
indirectly,  one  is  inclined  to  believe  that  the  average  of  human  life 
must  have  been  shorter  than  it  was  held  to  be  twenty  or  twenty-three 
centuries  ago.  There  is  no  room  to  enter  upon  a  discussion  of  the 
problem  here;  suffice  it  to  say,  the  loss  from  disease  was  probably  no 
greater,  and  the  losses  in  the  armies  probably  much  less  relatively  than 
in  modem  times.  For  it  is  well  known  that  the  killed  in  battle  are  but 
a  small  portion  of  those  whom  war  deprives  of  life.  It  is  probable 
that  never  before  or  since  has  any  country  suffered  such  ravages  as 
did  Germany  during  what  is  called  the  thirty  years  war.  That  the 
sanitary  condition  of  ancient  Greece  must  for  the  most  part  have  been 
fairly  good  is  attested  by  the  rapid  recuperation  of  most  of  the  city- 
states  after  a  disastrous  war.  But  then  there  were  no  large  cities 
like  those  of  modern  times,  in  which  the  population  increases  much 
faster  than  the  adoption  and  enforcement  of  sanitary  measures. 

It  will  hardly  be  considered  surprising  that  disease  in  any  form 
should  early  have  stimulated  men  to  reflection.  This  is  true  at  least 
of  those  living  under  conditions  where  there  was  more  or  less  freedom 
of  action  and  where  affairs  had  not  yet  settled  down  into  the  lethal 
routine  that  characterized  the  social  life  of  most  of  the  people  of  the 
ancient  world  anterior  to  the  appearance  of  the  Greeks.  The  succes- 
sion of  day  and  night;  the  changes  of  season  that  follow  each  other 
regularly,  and  the  meteorological  conditions  that  accompany  them, 
would  be  taken  as  a  matter  of  course.  But  the  vicissitudes  of  the 
human  system,  whether  gradual,  rapid  or  sudden,  when  not  the  result 
of  accident  or  attributed  to  the  malevolence  of  evil  spirits,  naturally 
led  to  inquiry  as  to  their  causes.  The  next  step  was  in  quest  of 
prophylactics  and  curatives.  This  sort  of  reasoning,  of  philosophy, 
was  not  obnoxious  to  the  charge  that  Socrates  brought  against  the 
philosophy  of  his  day,  namely,  that  it  was  concerned  wholly  with 
things  that  were  of  no  benefit  to  any  one  and  with  problems  to  which 
no  answer  could  be  found. 

^  [to  be  continued.] 


d2  MEDICAL  NEWS. 

MEDICAL  NEWS. 


PROFESSOR  ERNST  ZIEGLER,  PATHOLOGIST. 

Doctor  Ziegler^  whose  death  occurred  recently,  was  born  in  the 
neighborhood  of  Berne,  Switzerland,  in  1849.  He  studied  medicine  in 
his  native  city  and  also  at  Wiirzburg,  and  received  his  doctor's  degree 
at  Berne  in  1872.  He  qualified  as  privatdocent  at  Wiirzburg,  occupy- 
ing this  position  for  three  years,  when  he  went  to  Freiburg  in  Breisgau 
as  assistant  and  later  became  extraordinary  professor.  In  1881  he  filled 
the  chair  of  pathology  and  morbid  anatomy  at  Ziirich,  in  1882  he  went 
to  Tiibingen  in  a  similar  capacity,  and  in  1889  returned  to  Freiburg, 
where  he  remained  as  professor  of  patholc^y  until  the  time  of  his 
demise.  Doctor  Ziegler  was  a  prolific  writer  and  investigator,  and  con- 
tributed articles  on  inflammation,  tuberculosis,  rickets  and  neoplasms  to 
various  periodicals,  but  the  greatest  expression  of  his  work  is  embodied 
in  "Ziegler's  Pathology,"  which  was  first  published  in  1881,  and  through 
which  he  is  chiefly  known  to  American  students  and  physicians.  Besides 
being  professor  and  author  he  was  likewise  editor  of  two  of  the  most 
important  German  publications  on  pathology — ^the  Beitrdge  zur  allge- 
fneinen  Pathologic  und  pathologischen  AnatonUe  and  the  Zentralblatt 
fiir  allgemeine  Pathologic  und  pathologische  AnatonUe.  He  was 
engaged  in  the  revision  of  his  text-book  at  the  time  of  his  death  and 
had  so  far  progressed  with  the  work  that  with  slight  further  revision 
it  may  be  accepted  as  the  final  expression  of  his  opinion  on  pathology. 
He  was  highly  esteemed  as  a  man,  and  his  ability  as  a  lecturer  has 
been  attested  for  long  by  students  from  many  climes. 


MINOR  INTELLIGENCE. 


A  BILL  has  been  introduced  in  the  Massachusetts  legislature  to  pro- 
hibit the  publication  of  advertisements  referring  to  sexual  diseases. 

A  LATE  ordinance  of  the  city  of  Toronto  provides  that  the  houses  of 
persons  succumbing  to  tuberculosis  shall  be  disinfected  by  the  local 
health  officers. 

MiLAN^  Italy,  is  designated  as  the  next  meeting  place  of  the  Third 
International  Congress  of  Electrology  and  Radiology,  which  will  con- 
vene in  Sptember,  1906. 

The  Protestant  missions  have  been  instrumental  in  establishing  the 
Union  Medical  College,  of  Pekin,  China,  which  institution  was  opened 
for  instruction  February  13,  1906. 

A  BILL  has  been  introduced  in  the  New  York  legislature  forbidding 
the  marriage  of  imbeciles,  epileptics,  insane,  or  feeble-minded  persons. 
The  measure  also  prohibits  the  marriage  of  sound  persons  to  feeble- 
minded. 


MINOR    INTELLIGENCE.  08 

The  announcement  is  made  that  Karl  von  Noorden  has  been 
appointed  to  fill  the  chair  at  the  University  of  Vienna  made  vacant  by 
the  death  of  Professor  Nothnagel. 

Queen  Amelie,  of  Portugal,  who  is  a  doctor  of  medicine,  will  be 
honorary  president  of  the  Fifteenth  International  Medical  Congress, 
which  meets  in  Lisbon,  April  19,  1906. 

The  Health  Department  of  Havana  reports  that  three  patients,  suf- 
fering from  mild  attacks  of  yellow  fever,  are  still  confined  in  Las 
Animas  Hospital.     No  new  cases  have  recently  been  reported. 

The  Iowa  State  Board  of  Medical  Examiners  has  made  a  ruling  to 
the  effect  that  diplomas  granted  by  schools  which  allow  advanced  stand- 
ing for  work  done  outside  of  medical  schools  shall  not  be  recognized. 

The  City  of  Mexico  is  in  the  throes  of  an  epidemic  of  typhus  fever. 
The  disease  is  attributed  principally  to  bad  sanitary  conditions  in  the 
city,  and  stringent  measures  toward  remedying  them  are  being  enforced. 

The  plans  submitted  for  the  new  army  hospital  at  Washington 
have  been  approved  by  Secretary  Taft.  The  estimated  cost  of  the 
building  is  $300,000,  Congress  having  limited  the  appropriation  to  this 
amount. 

The  Chicago  Women's  Club  has  inaugurated  a  campaign  against 
venders  of  impure  milk,  and  the  various  female  organizations  of  the 
city  will  be  asked  to  subscribe  $1,500  annually  to  provide  a  salary  for  a 
competent  milk  inspector. 

Doctor  Lehman  H.  Dunning,  of  Indianapolis,  a  well-known  gyne- 
cologist and  for  several  years  professor  of  gynecology  and  abdominal 
surgery  in  the  Indiana  Medical  College,  died  at  his  home  on  January  4, 
1906,  aged  fifty-five  years. 

Doctor  Clara  Marshall  has  resigned  the  Chair  of  Materia 
Medica  and  Therapeutics  in  the  Woman's  Medical  College  of  Pennsyl- 
vania. The  doctor  has  been  connected  with  the  teaching  force  of  the 
institution  for  over  thirty  years. 

A  SITE  has  been  chosen  in  the  town  of  Pittsford  for  Vermont's  new 
tuberculosis  sanitorium.  The  institution  is  a  gift  to  the  state  from 
Senator  Redfield  Proctor,  and  the  projectors  anticipate  the  completion 
of  the  buildings  by  next  winter. 

The  passage  of  a  bill  in  the  New  York  Assembly,  on  March  6,  pro- 
vides for  the  appointment  of  two  more  health  commissioners  for  the 
city — one  for  the  Boroughs  of  Manhattan,  Richmond,  and  Bronx,  and 
one  for  the  Boroughs  of  Brooklyn  and  Queens. 

The  will  of  the  late  Doctor  George  S.  Hyde  provides  that  $50,000 
be  turned  over  to  the  Harvard  Medical  School  upon  the  death  of  E.  P. 
Hyde  and  Mrs.  Aniie  M.  Sargent,  brother  and  sister  of  the  deceased. 
The  doctor  was  connected  with  this  institution  prior  to  his  demise  last 
year. 


94  MEDICAL  NEWS. 

At  the  twenty-ninth  annual  meeting  of  the  Illinois  State  Board  of 
Health,  which  was  held  recently  at  Springfield,  Doctor  George  W. 
Webster,  of  Chicago,  was  elevated  to  the  presidency,  and  Doctor  James 
A.  Egan,  of  Springfield,  was  reelected  to  the  secretaryship. 

Dissension  exists  between  the  physicians  and  druggists  at  Bayonne, 
New  Jersey,  because  the  latter  persist  in  counter  prescribing.  A  state 
law  prohibits  any  person  except  a  physician  frc«n  prescribing  for  the 
sick,  but  the  druggists  have  engaged  counsel  and  will  institute  a  test 
case. 

A  SUM  of  $8,000  has  already  been  subscribed  toward  the  erection  of 
a  $10,000  memorial  to  the  late  Doctor  Joseph  Leidy  in  consideration 
of  his  invaluable  contributions  to  the  natural  sciences.  The  monument 
will  be  presented  to  the  city  of  Philadelphia,  the  field  in  which  the 
scientist  worked  and  died. 

Reports  recently  submitted  to  the  Mississippi  legislature  by  the 
State  Board  of  Health  disclose  an  expenditure  of  over  $43,000  during 
the  past  year  in  consequence  of  the  yellow  fever  epidemic.  Fifteen 
localities  were  infested,  the  total  record  showing  eight  hundred  thirty- 
seven  cases  and  sixty-one  deaths. 

The  sum  of  $13,000  was  realized  from  the  New  York  German 
charity  ball  which  was  held  in  January.  Of  this  amount  $2,300  was 
given  to  the  German  Hospital  and  Dispensary,  and  smaller  amounts 
were  donated  to  Saint  Mark's  Hospital,  the  West  Side  German  Dis- 
pensary, and  Saint  Francis'  Hospital. 

Doctor  Samuel  R.  Wooster,  late  president  of  the  Grand  Rapids 
Academy  of  Medicine,  died  from  the  effects  of  a  surgical  operation  on 
February  6,  aged  sixty-six  years.  Doctor  Wooster  was  a  graduate  of 
Yale  and  during  the  Civil  War  was  connected  with  several  Michigan 
regiments  in  the  capacity  of  army  surgeon. 

»The  will  of  Charles  L.  Yerkes,  the  deceased  street  railway  mag- 
nate, bequeathes  $800,000  for  the  purchase  of  a  site  and  erection  of  hos- 
pital buildings  thereon  in  the  Borough  of  Bronx.  Provision  is  also 
made  for  the  maintenance  of  the  institution.  The  income  arising  from 
a  sum  of  $5,000,000  will  be  utilized  for  this  purpose. 

Professor  Ernst  von  Bergmann,  the  eminent  German  physician, 
has  been  raised  to  life  membership  in  the  upper  house  of  parliament  by 
the  German  Emperor.  Professor  von  Bergmann  is  the  author  of  the 
work  on  surgery  which  bears  that  name,  and  is  the  first  physician  to  be 
elevated  to  the  dignity  of  membership  in  the  German  parliament. 

The  next  meeting  of  the  Association  for  the  Advancement  of 
Science  will  be  held  in  New  York  City  on  December  27,  1906.  At  the 
recent  meeting  in  New  Orleans  the  following  officers  were  elected  for 
the  ensuing  year:  President,  William  H.  Welch,  of  Johns  Hopkins; 
general  secretary,  John  F.  Hayford;  secretary  of  council,  F.  W. 
McNair. 


AUTOINTOXICATION  IN  DISEASE.  95 

After  several  setbacks  the  osteopaths  have  renewed  their  efforts  to 
establish  recognition  of  their  cult  in  the  state  of  New  York.  The 
Davis  bill,  which  is  intended  to  create  an  osteopathic  examining  board 
under  the  Regents  of  the  State  University,  was  recently  given  public 
hearing  before  the  Senate  Judiciary  Committee.  Several  physicians 
and  laymen  spoke  in  opposition  to  the  bill,  contending  that  its  passage 
would  permit  persons  unqualified,  by  reason  of  meager  medical  knowl- 
edge, to  engage  in  medical  practice.  The  only  supporters  of  the  bill 
were  four  osteopaths  from  different  New  York  cities. 


RECENT  LITERATURE. 


REVIEWS. 

THE  READY  REFERENCE  HANDBOOK  OF  DISEASES  OF 

THE  SKIN.* 

This  last  edition  of  Doctor  Jackson's  well-known  and  popular  hand- 
book contains  the  addition  of  much  new  material  in  text  and  illustra- 
tion. It  is  among  the  best  of  handbooks,  and  while  the  alphabetical 
arrangement  of  diseases  does  not  commend  itself  to  the  specialist  or 
teacher,  it  will  appeal  to  the  practitioner  who  wishes  to  get  at  the  gist  of 
pathology,  diagnosis,  and  treatment  of  a  given  case — if  only  tentatively 
— ^in  the  shortest  time.  The  style  is  clear  and  concise,  and  the  book  will 
advance  the  position  the  former  editions  held  as  a  valuable  and  trust- 
worthy guide  in  the  care  of  diseases  of  the  skin.  A  useful  appendix 
contains  suggestive  formulae  for  external  applications,  as  well  as  for 
internal  medication.  w.  f.  b. 

♦By  George  F.  Jackson,  M.  D.  Fifth  edition,  thoroughly  revised, 
making  a  12-mo.  volume  of  676  pages,  with  ninety-one  engravings  and 
three  colored  plates.  Cloth,  $2.75,  net.  Lea  Brothers  &  Company, 
Philadelphia  and  New  York,  1905. 


SELF-POISONING  OF  THE  INDIVIDUAL.* 
The  reprinting  of  this  well-known  work  seems  to  indicate  a  con- 
tinued demand.  This  being  so,  it  is  unfortunate  the  whole  book  was 
not  rewritten.  It  is  hard  to  patch  the  stuff  of  the  last  twelve  years' 
work  upon  the  well-worn  garment  of  the  former  time,  and  Doctor 
Oliver  has  only  made  this  clearer  by  his  well-meant  endeavors.  The 
things  that  made  the  first  edition  popular  are  still  here — ^the  assurance 
of  certainty,  the  simple  faith  in  antiseptics,  but  they  fall  on  stonier 
ground  than  before.  Let  us  hope  the  next  edition  will  give  us  what 
the  first  promised.  G.  d. 

♦By  Ch.  Bouchard^  Professor  of  Pathology  and  Therapeutics; 
Member  of  the  Academy  of  Medicine  and  Physician  to  the  Hospitals, 


96  RECENT  LITERATURE. 

Paris.  Translated,  with  a  Preface  an^  New  Chapters  added,  by 
Thomas  Oliver,  M.  A.,  M.  D.,  F.  R.  C.  P.,  Professor  of  Physiology, 
University  of  Durham ;  Physician  to  the  Royal  Infirmary,  New  Castle- 
Upon-Tyne;  formerly  Examiner  in  Medicine,  Royal  College  of  Physi- 
cians, London.  Second  revised  edition.  Crown  octavo,  342  pages. 
Extra  cloth.  Price,  $2.00,  net.  F.  A.  Davis  Company,  Publishers, 
1914-16  Cherry  Street,  Philadelphia. 


PRACTICAL  PEDIATRICS.* 

This  treatise  on  the  medical  and  surgical  diseases  of  childhood  is 
certain  to  rank  as  one  of  the  best  books  of  the  kind  for  the  busy  practi- 
tioner or  for  the  student  preparing  for  examination.  It  is  brief  and  to 
the  point,  as  the  author  has  omitted  superfluous  material.  The  Ameri- 
can translator  has  made  many  additions  and  inserted  notes  which 
enhance  the  value  of  the  book.  An  excellent  chapter  devoted  to  the 
"Materia  Medica  and  Theurapeutics  of  Childhood"  concludes  the  work. 
The  book  is  most  attractively  executed  and  the  parts  are  well  arranged. 

A.  D.   H. 

*A  Manual  of  the  Medical  and  Surgical  Diseases  of  Infancy  and 
Childhood.  By  Doctor  E.  Graetzer,  Editor  of  the  Centralblatt  fur. 
Kinderheilkunde  and  the  Excerpta  Medico.  Authorized  translation, 
with  numerous  Additions  and  Notes,  by  Herman  B.  Sheffield,  M.  D., 
Instructor  in  Diseases  of  Children,  and  Attending  Pediatrist(0.  P.  D.) 
New  York  Post-Graduate  Medical  School  and  Hospital ;  Visiting  Pedi- 
atrist  to  the  Metropolitan  Hospital  and  Dispensary,  et  cetera.  Pages 
XII-544.  Crown  octavo,  flexible  cloth,  round  comers.  Price,  $3.00 
net.  F.  A.  Davis  Company,  Publishers,  1914-16  Cherry  Street, 
Philadelphia. 

THE  PHYSICAL  EXAMINATION  OF  INFANTS  AND 
YOUNG  CHILDREN.* 

An  inexpensive,  neat  little  book,  full  of  many  practical  suggestions 
for  those  who  desire  to  acquaint  themselves  with  the  various  methods 
of  examining  children.  The  illustrations  are  clear  in  detail.  There  is 
only  one  subject  of  importance  in  the  examination  of  children  the 
author  fails  to  clear  up  for  the  reader,  that  is,  how  to  induce  the  child 
to  become  so  "pleased  to  meet  you."  The  majority  of  the  illustrations 
present  a  smiling  nurse  and  doctor  and  a  perfect  angel  of  a  patient, 
almost  like  the  catatoniac  whose  arm  stays  where  you  put  it. 

*By  Theron  Wendell  Kilmer,  M.  D.,  Adjunct  Attending  Pediatrist 
to  the  Sydenham  Hospital ;  Instructor  in  Pediatrics  in  the  New  York 
Polyclinic  Medical  School  and  Hospital,  New  York;  Attending  Phy- 
sician to  the  Summer  Home  of  Saint  Giles,  Garden  City,  New  York. 
Illustrated  with  fifty-nine  half-tone  engravings.  i2mo,  86  pages. 
Bound  in  extra  cloth.  Price,  75  cents,  net.  F.  A.  Davis  Company, 
Publishers,  19 14- 16  Cherry  Street,  Philadelphia. 


%  Jtesician  aiilr  Surgeon 

A  PROFESSIONAL  MEDICAL  JOURNAL. 


VOLUMB  XXVIII.  MARCH,  1906.  NUMBER  III. 


ORIGINAL  ARTICLES. 


MEMOIRS. 


CONGENITAL  LUXATION  OF  THE  HEAD  OF  THE  RADIUS.* 

REPORT  OF  TWO  CASES.     ANALYSIS  OF  FIFTY-ONE  CASES.     SUMMARY. 
CER  TAIN  O  THER  CONSIDER  A  TIONS.     COXCL  USIONS. 

By  WILLIAM  E.  BLODGKTT.  M.  D..  Detroit.  Michigan. 

The  concurrence  of  two  new  cases  of  congenital  luxation  of  the 
head  of  the  radius,  with  failure  to  find  a  thorougli  review  of  the  sub- 
ject directly  based  on  the  observed  facts,  has  led  to  the  present  paper. 
Nearly  all  the  cases  here  included  are  referred  to  by  Powers,*  Blumen- 
thal,^  Bonnenberg,^  or  Abbott,*  to  whom  the  author  is  indebted  for 
most  of  his  data;  but  it  is  believed  that  a  uniform  analysis  of  each 
case  and  collation  and  summary  of  the  entire  group  is  needed. 

The  plan  of  the  paper,  therefore,  is  to  (I)  report  the  author's  two 
cases,  (II)  analyse  the  fifty-one  cases,  (III)  summarize  the  group, 
(IV)  consider  certain  features  of  the  subject  not  covered  by  the  sum- 
mary, and  (V)  draw  conclusions. 

I.— REPORT  OF  CASES. 

Case  L — A  girl,  fifteen  years  old.  No  miscarriages  or  other  sug- 
gestion of  syphilis  in  family  history.  No  abnormalities  in  parents  or 
in  brothers  or  sisters.  The  trouble  in  the  arms  was  first  noticed  when 
it  was  found  that  the  young  baby  could  not  hold  a  lump  of  sugar  on 
either  palm.     Three  years  ago  while  arranging  her  hair,  the  patient 

♦Presented  by  invitation  at  the  nineteenth  annual  meeting  of  the  American 
Orthopedic  Association,  at  Boston,  June  6-8.  1905. 


98  ORIGINAL  ARTICLES. 

had  sudden  pain  in  the  left  elbow  upon  attempting  to  extend  it;  no 
pain  when  the  elbow  was  at  rest  in  flexion.  This  difficulty  in  exten- 
sion continued  several  months.  An  anesthetic  showed  that  the  obstacle 
to  extension  was  muscular.  The  difficulty  gradually  disappeared. 
Neither  elbow  has  at  any  time  been  swollen  or  tender.  No  other 
deformities.  Excellent  general  health.  The  chief  complaint  is  of  par- 
tial disability  of  either  arm,  illustrated  by  the  patient's  inability  to 
grasp  a  plate  or  a  spoon  with  the  thumb  on  the  upper  surface.  There 
is  also  unusual  liability  to  fatigue  in  the  arms. 


FIGURE    I. — RIGHT     ELBOW,    CASE    I,     SHOWING    ANTERIOR    DISLOCATION    OF    HEAD    OF 
RADIUS,    ELONGATION    OF    RADIUS,    AND    FUSION    OF    RADIUS   AND    ULNA. 

Patient  is  well  developed  and  nourished.  Examination  of  parts 
other  than  the  arms,  negative.  The  forearms  are  fixed  in  respect  to 
rotary  motion  in  full  pronation.  Flexion  and  extension  are  free  and 
strong.  Hyperextension  beyond  straight  sixteen  degrees  on  left  and 
twenty  degrees  on  right.  Relation  of  condyles  and  olecranon  appar- 
ently normal.  Distal  to  the  external  condyle  and  the  capitellum,  the 
space  iiormally  occupied  by  the  head  of  the  radius  is  vacant.  On  the 
llexure  surface  of  the  elbow,  anterior  to  this  vacant  space,  is  plainly 
felt  a  hard,  globular  body,  size   of  the   index   finger,  moving  with 


CONGENITAL  LUXATION  OF  RADIAL  HEAD. 


09 


movement  of  the  forearm.  The  tendon  of  the  biceps  passes  down  on 
the  inner  side  of  this  body.  No  atrophy  apparent.  No  other  abnor- 
malities of  arms.     The  two  elbows  are  alike. 

Radiographs  show  on  each  side  an  anterior  luxation  of  the  radial 
head,  excessive  length  of  the  upper  end  of  the  radius,  absence  of  the 
normal  slight  anterior  concavity  of  the  lower  end  of  the  shaft  of  the 
humerus,  and  cancellated  bone  fusion  of  the  radius  above  the  tubercle 
with  the  ulna.  Radiographs  of  the  forearms  and  wrists  show  nothing 
abnormal,  except  that  bones  are  small  for  age. 


FIGURE     II. — LEFT    ELBOW     OF    NORMAL    GIRL,    SAME    AGE.         SAME     POSITION     AS     IN 

FIGURE  I. 

The  temporary  inability  to  extend  the  left  elbow  without  pain  is 
to  be  explained  by  a  sprain,  to  which  such  an  imperfect  joint  would 
be  especially  liable.  Excision  of  the  radial  head,  the  only  operative 
procedure  to  be  considered,  was  believed  unindicated  by  the  amount 
of  disability  present. 

Case  II. — (Through  courtesy  of  Doctor  Daniel  LaFerte,  Detroit). 


100 


ORIGINAL  ARTICLES. 


A  boy,  six  years  old.  No  syphilitic  history  or  abnormality  in  family. 
Since  birth,  the  forearms  were  fixed  in  extension  and  pronation. 
Radiographs  taken  two  years  ago  show  bilateral,  anterior  luxation  of 
the  radial  head,  elongation  of  the  upper  end  of  the  radius,  and  no  bone 
fusion.  Owing  to  the  permanent  extension,  the  disability  was  great. 
About  two  years  ago,  Doctor  LaFerte  excised  the  upper  end  of  the 
radius  on  each  side,  taking  care  not  to  disturb  the  insertion  of  the 


FIGURE    III.- 


LEFT    ELBOW,   CASE    I,   SHOWING    DISLOCATION    ELONGATION,    AND    FUSION. 
PRONATKD    POSITION. 


biceps.  This  was  followed  by  riianipulative  mobilizations,  which,  how- 
ever, were  discontinued  by  the  patient  sooner  than  advised.  The  child 
also  had  double  club-foot,  which  was  operated  on  with  good  result. 
When  the  boy  was  seen  by  the  author  two  years  after  the  operation, 
the  mother  stated  that  the  boy  could  now  feed  himself,  and  that  the 
arms  were  improved,  although  the  child  still  grasped  objects  with 
the  thumb  underneath.  Passive  flexion  on  both  sides  was  found  to 
reach  to  a  right  angle,  and  passive  extension  to  within  twenty  degrees 
of  straight;  no  power,  however,  on  either  side  in  flexion  or  extension. 


CONGENITAL  LUXATION  OF  RADIAL  HEAD. 


101 


The  right  elbow  is  permanently  pronated,  and  the  left  is  in  ninety 
degrees  of  pronation  and  allows  a  few  degrees  of  rotary  motion. 

Radiographs  show  what  appears  to  be  a  partial  regeneration  of  the 
heads  of  the  radii  in  the  anterior  position. 


FIGURE   IV.- 


-LEFT    ELBOW   OF   NORMAL   GIRL,   SAME    AGE. 
FIGURE    III. 


SAME    POSITION    AS   IN 


II.— ANALYSIS  OF  FIFTY-ONE  CASES. 


C/3 

H 

is  Q 

5   . 

2 
0 

>: 

i« 

-<  < 

oi  Z 

^ 

''■ 

CASE 

Q 

n 
0 

Si 

Si 

THER 

BFORM 

lES 

REMARKS 

ss 

M 

>-) 

S 

bd  H 

b.  < 

0  Q  H 

(i)    Bonnenbcrg* 

F 

R 

For- 
ward 

Free  flex'n. 
155"  ex- 
tension. 

Yes 

No 

Excision  head  of  ra- 
dius and  lower   end 
ulna.     Osteotomy 
shaft  radius  to 
straighten.     Result: 
pronated   position, 
with    slight    passive 
and  no  active  supi- 
nation;   free  flexion 
and  extension. 

(2)    Dupuytren* 

Both 

Back- 
ward 

Yes 

Necropsy. 

102 


ORIGINAL  ARTICLES. 


(3)    Dupuytren* 


(4)    Servier' 


(5)    Herskovitz* 


(6)    Homphrey* 


(7)    Mitscherlich" 


(8)    Allen" 


(9)    Pyc-Sinith»2 


(10)  Phillips" 


{ii)Hccle" 


M 


Both 


Both 


Both 


M 


M 


Both 


Both 


Both 


Both 


Both 


•J 


Back- 
ward 


Back 
ward 


Back 

ward 


For- 
ward 


For- 
ward 


Back 

ward 


Back 
ward 


Back- 
ward 


Back 
ward 


o 

2 


Supination 
limited. 
No  mention 
flexion  or 
extension. 

Half  pro- 
nation to 
fall  prona- 
tion. 

Free  flex- 
ton.  120'' 
extension. 


Extension 

free. 
Flexion  on 

R.  to  7o% 

L.to  110**. 

Snpinated. 

Extension 
only  to 
right  an- 
gle.    No 
rotation. 


Extension 
free. 

Flexion 
nearly 
free. 

Semipro- 
nated. 

Slight   ro- 
tation. 

Normal, 
but  supi- 
nation 
weak. 


o  < 


Yes 


Yes 


Yes 


Yes 


en 

& 

s 

•<  •< 

at  Z 
O  ^ 

^  9 

k.  < 


No 


Yes 


at 


Absence 
lower 
part  of 
left  ulna. 

Club- 
foot 

Defect  of 
knees. 


Forearm 

concave 

toward 

radical 

side. 


Defect 

lower 

ulna. 

Club- 
foot 


Hyper- 
trophy 
external 
condyle. 


REMARKS 


Radial  head,  upon 
rotation  of  farearm, 
circumducts  in  circle 
of  3  c  m.  radius. 


Necrcipsy  only. 


Complete  excision 
elbow.     Death. 
Specimen   shows  no 
contact   at   all   be- 
tween head  of  radius 
and  ulna. 

Necropsy.  No  his- 
tory of  presence  in 
early  life. 


Noticed  early  in  life. 
In  family  of  eleven, 
eight  had  joint  de- 
formities. 

Noticed  shortly  after 
birth. 


Noticed  early  in  life. 
Loose- jointed.  In- 
telligince  backward. 
Right  always  luxated 
— left,  usuidly. 


CONGENITAL  LUXATION  OF  RADIAL  HEAD. 


103 


CASE 


(i2)Machenhauer>* 


(13)  Adams^* 


(14)  Adams^' 


(15)  Dcvillc" 


(16)  Senftlebcn** 


(17)  Adams'* 


(18)  Adams" 


(19)  Cruvcilhicr** 


(20)  Cruveilhicr** 

(21)  Sandifort* 

(22)  Sandifort* 

(23)  Dubois* 

(24)  Vcrneil* 

(25)  Sandifort* 


M 


M 


M 


M 


Both 


Both 


o 

< 
X 
D 
•J 


For 
ward 


One 


R 
One 
One 
One 
One 

R 


Out- 
ward 


Out. 
ward 


Out- 
ward 


Back- 
ward 


Back- 
ward 


Back- 
ward 


In- 
ward 
and 
for- 
ward 


Extension 

to  165° 

Flexion  to 

Supination 
and  prona- 
tion free. 

Free  ex- 
cept in  ex- 
tension. 

No  exten- 
sion or 
flexion. 

Supination 
and  prona- 
tion free. 

Freer  than 
normal. 


Normal. 


In  position 
of    semi- 
flexion 
and  full 
pronation. 


Extension 
limited. 

No  supina- 
tion. 


Pronated. 


No  supina- 
tion. 


«3 

<  u. 
o  o 


Yes 


Yes 


Yes 


Yes 

2  in. 


Yes 


Yes 


Yes 


Yes 


<  < 
t4  Z 


o  ^ 

^  s 

u.  •< 


No 


No 


Yes 


gas 

H  M  M 

O  Q  H 


No. 


Other  de- 
formities 
of  elbow. 

Defects 
in  other 
joints. 


Deficien 
cy  middle 
of  ulua. 


Defici- 
ency 
shaft  of 
ulna. 


Forearm 
concave 
on  ulnar 
side. 


Necropsy.   Radial 
head  excessively 
large. 


Necropsy.  Soft  parts 
normal.     Fibrous 
band  in  place  of  mid- 
dle of  ulna.  Forearm 
concave  on  ulnar  side 

Fibrous  cord  in  place 
of  middle  of  ulna. 
Forearm  concave  on 
ulnar  side. 

Preparation.        fio 
trace  of  capitellum. 


Preparation.     "Cari- 
ous" process  in  joint. 


Preparation. 


Necropsy. 


Preparation. 


104 


ORIGINAL  ARTICLES. 


CASE 

X 

M 

F 

R 

0 

< 

Back 

ward 

> 

H 

1        ' 

Suptnafion 

limited. 

Semiflexed* 

J 

c  ■< 

5t 

^  1 

0  ^ 
-1  a: 

Yes 

3 

<  < 

Si 

REMARKS 

(26)  Bessel- 

Hagen» 

External 
condyle 
hypertro- 
phied. 
Gigant- 
ism of 

Excision  head  of  rad- 
ius, foUowed  hyman- 
ipulalions  under  an- 
eiithesia.        Result 
one  year  after  opera- 
lion:    normal   mobil* 

» 

1 

arms* 

ity* 

(27)  Bessel- 

Hagen^ 

K 

back- 
ward 

AH  motions 
limited. 

Semipro- 
nated  and 
semiflexed. 

Ves 

Various 

exostoses 

and  de- 

fecis. 

Forearm 

smaller 

Ulna    undeveloped, 
and  deficient  at  car- 
pal end. 

!■ 

and    con- 

cave on 
I  ulnar 
side. 

(28)  Bessel- 

Hagen» 

M 

L 

Back 
ward 

Extension 
onlv 

limited* 

Ves 

Varioui* 
defects* 
Forearm 
smaller 
and   con- 
cave on 
ulnar 
^ide. 

Eiead  circumducts 
in  rotalioD  of  £ore- 
arro. 

(29)  Smith" 

F 

One 

For- 
ward 

From  90^ 
to  nearly 
straight 
Pronation 
and  supina- 
tion lim- 
ited. 

External 
condyle 
enlarged* 
Congeni- 
tal luxa- 
tion of 
wrist  and 
knee. 

No  trochlea  or  capi- 
tellum< 

(30)  Smith" 

F 

One 

<( 

Slight  ex- 
tension 
from  90*" 
permanent 
flexion. 
Pronation 
and  supi- 
nation 
limited. 

Yes 

Yes 

External 

condyle 

enlarged. 

Deficient 

ulna. 

No  capitellum.  Hole 
for  radial   head   be- 
tween  imperfect 
trochlea  and    exter- 
nal condyle. 

(31)  Toppich» 

M 

L 

(« 

Free 

Yes 

Tuberculosis    other 
elbow. 

(32)  Leisrink** 

M 

Both 

Extension 
and  flexion 
nearly  free. 
Supination 
and  prona- 
tion much 
limited. 

Luxata- 
ble  left 
ulna. 

Resuscitated  after 
delivery  by  vigorous 
means.   First  noticed 
at  third  year. 

CONGENITAL  LUXATION  OF  RADIAL  HEAD. 


105 


CASK 


(33)  Abbott* 


(34)  Abbott* 


(35)  Abbott* 

(36)  Abbott* 


(37)  Abbott* 


{38)  Abbott* 


(39)  Abbott* 


<40)  Abbott* 


M 


M 


M 


Both 


For- 
ward 


Both'     " 
Both      '* 


Buih 


Botb      " 


M  Br>th 


Back 

ward 
and 
in- 
ward 


> 

i 

J 

4  bi 

Extenfiion 

and  flexion 
free.  Fixed 
in  fietni- 
pronation. 

Ye> 

Yes 
witli 

cen- 
ter of 
oulfi 

CMtEw 

No 

Ex  ten  a  ion 
and  flex  ton 

free.  Fixed 
in  fieroi- 
pronation. 

Yes 

V€S 

No 

As  above, 
but  left  has 
only  sHgbt 
check  to 
supination. 

Ves 

Ves 
It 

11 

Extension 
and  fleaion 
free.  Fixed 
in  £]mi- 
pronation* 

Yes   1 

Ye« 

ft 

Yes 

Ye» 

tl 

ti 

li 

n 

it 

All  motions 
restricted. 

Yes 

Club- 
foot. 
Disloca- 
tion 
patella. 

Noticed  early  in  life. 
The  presence  of  the 
lesser  sigmoid  cavity 
and  the  smooth  arti- 
cular cartilage  on  the 
head  indicate  to  Ab- 
bott that  the  primary 
lesion  is  the  over- 
growth of  head  and 
neck,  resulting  in  fu- 
sion (due  probably  to 
the  center  normally 
forming  the  coronoid 
process). 

Noticed  early  in  life. 


Noticed  early  in  life. 
Not  seen  by  Abbott, 
but  credibly  reported 
to  him  to  be  entirely 
similar  to  his  other 
cases. 

Noticed  early  in  life. 
Not  seen  by  Abbott, 
but  credibly  repoted 
to  him  to  be  entirely 
similar  to  his  other 
cases. 

These  seven  cases 
occured  in  one  fami- 
ly, covering  four  gen- 
erations. 

Dissection. 
Apparently  due  to 
deformity  of  lower 
ends  of  humeri. 
Capitellum  well- 
formed,  and  larger 
than  usual. 


106 


.ORIGINAL  ARTICLES. 


(41)  Abbott^ 


(42)  Voigt" 


(43)  Schmidt" 


(44)  Blumentb&l' 


(45)  Powers* 


(46)  Ambard" 


M 


M 


M 


(47)  Bcrgtold* 


(48)  Hamilton" 

(49)  Guerin*" 


One 


One 


Both 


Back 
ward 
and 
out- 
ward 


Back 
ward 


For 
ward 


Back 
ward 


o 


Extension 

slightly 

limited. 
Flexion 

free. 

No  supina- 
tion beyond 
midpoint. 


Excessive 
flexion  to 
140°  of  ex- 
tension on 
R.      Free 
flexion  and 
extension 
on  L.     Al- 
most no 
supination 


For-    Almost  no 


Both 


ward 
and 
out- 
ward 


Out- 
ward 


Both 


Both 
Both 


supination 
No  active 

flexion. 
Passive 

flexion  to 

Free  and 
strong. 


For- 

word 


'^  9 
o  •< 

2g 


Extension 
and  flexion 
free.  Fixed 
in   prona- 
tion. 

Normal. 


Yes 


Yes 


Yes 


<  < 

o  ^ 

^  5 

u.  < 


No 


Yes 


No 


H  M  S 
O  Q  H 


Defect  of 
radius  on 
other 
side. 

Defect  of 
radius  on 
affected 
side. 

Forearm 
on  R. 
shorter, 
and  rad- 
ius con- 
cave in- 
ward. 


No 


Nasal 
caries. 
Syphili- 
tic? 


Yes 


No 


Noticed  early  in  life. 
Capitellnm  well- 
formed,  and  larger 
than  usual. 


Radial  bead  luxata- 
ble  upon  extension. 


Sister,     father,    and 
paternal  grand- 
father said   to   have 
same  deformity. 
Radiographs. 


Noticed  three    days 

after  birth. 

Left  arm  shorter. 

Radiograph. 


Noticed  early  in  life. 
Applied  for  treat- 
ment for  excoriations 
over  prominence  of 
head  of  radius  on 
outer  side  of  either 
elbow. 

Luxation  believed  by 
Ambard  to  be  con- 
genital effect  of 
hereditary  syphilis. 


Generally  loose- 
jointed. 


CONGENITAL  LUXATION  OF  RADIAL  HEAD. 


107 


OD 

2 

g 

g^ 

^ 

CASE 

X 

S 

I 

0  0 

1^ 

^  9 

THER 

EFORM 

lES 

REMARKS 

M 

n 

D 

0 

2  2 

D  S5 

en 

M 

•J 

X 

M  M 

U.   «< 

0  Q  H 

(50)  LaFertd«» 

M 

Both 

For- 

Nearly  fixM 

Yes 

No 

Club- 

Noticed  early  in  life. 
Excision  radial 

ward 

in  exten- 

foot. 

sion  and 

heads.      Result  after 

pronation. 

two  years:  passive 
but  no  active  flexion, 
no  rotary  mobility. 

(51)  Blodgett** 

F 

Both 

4* 

Extension 

and  flexion 

free. 
Fixed  in 

pronation. 
Hypcrex- 

tensible. 

Yes 

Yes 

No 

Noticed  early  in  life. 

III.— SUMMARY. 

(J)  Sex. 

Male 

22.            61.1%. 

Female 

14.            38.9%. 

Unrecorded 

15- 

Of  bilateral  cases : 

Male 

17.           77.3%. 

Female 

5.           22.7%, 

Unrecorded 

(2)  Side, 

3. 

Both 

25-           50.0%. 

One  only 

25.           50.0%. 

Unrecorded 

I. 

Of  unilateral  cases : 

Right 

9.           56.2%. 

Left 

7.           43.8%.       . 

Un 

recoi 

rded 

9 

• 

(j)  Direction  of  Lujfation. 


Backward 

Forward 

Outward 

Inward 

Unrecorded 


23. 

46.0%. 

20. 

40.0%. 

6. 

12.0%. 

I. 

2.0%. 

I. 

In  the  bilateral  cases  the  direction  of  luxation  was  always  the  same  on  the 
two  sides. 


108 


ORIGINAL  ARTICLES. 


(4)  Mobility. 
Table  A. 
Backward.    Forward.     Outward.    Inward.     Unrecorded.    Total. 


Freer  than 

normal 

Normal  i.    5.6%. 

Restricted       17.  94-4%. 

Unrecorded      5. 


1.  16.7%. 
I-    5.9%.       3.  50.0%. 
16.  94i%-        2.  33-3%- 
3. 


I.    24%. 

5.  11.6%. 

37'  96.0%. 


Table  B. 


Extension. 
Flexion. 
Pronation. 
Supination 


Free  or 
nearly  free 
(including  cases 
fixed  in  the  ex- 
treme of  motion.) 

21.  60.0%.  14.  40.0%. 

22.  64.7%  12.  35-3%  • 
27.  62.8%.  16.  37.2%. 
12.  27.9%.           31.  72.1%. 


Restricted.    Unrecorded. 


16. 

17. 
8. 
8. 


Table  C* 
Backward.    Forward.    Outward.    Inward.    Unrecorded.    Total. 


Extension 
free  or 
nearly  free. 

Flexion 
free  or 
nearly  free. 

Pronation 
free  or 
nearly  free, 
including 
cases  fixed 
in  full 
pronation. 

Supination 
free  or 
nearly  free. 


3.  13.0%.     13-  65.070.      5-  83.3%- 


II.  47.8%.      6.  30.0%.      5.  83.3%. 


21. 


22. 


14.  60.9%.      5.  25.0%.      6.  100.0%. 

2.    8.7%.      4.  20.0%.      5.  83.3%. 

(5)  Elongation  Upper  End  of  Radius. 

In  backward  luxations  18. 

IS. 


27. 


12. 


In  forward  luxations 
In  outward  luxations 
Direction  not  recorded 
Total 


78.3%. 
75.0%. 
66.7%. 


4. 
I. 
38.    74.5% 


*The  precentages  in  Table  C.  are  based  on  the  whole  number  of  luxations  in  the 
direction  under  consideration;  thus  100  %  of  the  outward  luxations  have  free  pronation 
because  six  have  this  movement  free  and  there  are  only  six  outward  luxations  in  all. 


CONGENITAL  LUXATION  OF  RADIAL  HEAD, 
(d)  Bone  Fusion  Upper  Part  Radius  and  Ulna. 


10» 


In  backward  luxations 
In  forward  luxations 
In  outward  luxations 
In  inward  luxations 
Total 

6  (4  single,  2  double). 

ID   (4  single,  6  double) . 

0. 

I    (single). 

17    (9  single, 8 double). 

26.1%. 
50.0% 

33.3% 

::ases  with  fusion: 

No  rotation 
Almost  no  rotation 
Unrecorded 
Pronated  position 
Semipronated  position 
Unrecorded 

14- 
2. 
I. 
6. 
7. 
4. 

(7)  Other  Deformities. 

Bone  deficiency  in  forearm                          7 
Club-foot                                                        5. 

Other  deformities  of  elbow. 

(besides  those  directly  refer- 
able to  the  luxation  of  the  head 
of  the  radius) 

Lateral  curve  of  forearm. 
(3  concave  on  ulnar  side, 
I  concave  on  radial  side). 

Other  joints  defective 

Total 


4. 

2. 

-22. 


431%. 


IV.— CERTAIN  OTHER  CONSIDERATIONS. 

(i)  Incidence, 

Stimson'^  quotes  Kronlein's'*  statement  *'that  the  records  of  Von 
Langenbeck's  polyclinic  show  90  congenital  dislocations  of  the  hip, 
5  of  the  shoulder,  2  of  tlTe  head  of  the  radiuis,  and  i  of  the  knee.'' 
Congenital  dislocation  of  the  hip,  the  cotnmonest  of  the  congenital 
dislocations,  was  found  by  Chaussier  once  m  23,293  infants  born  at 
the  Maternite,  although  Parise,  in  332  hip  dissections  of  all  the  children 
who  died  at  the  Hospital 'des.  En f ants  Trouves,  found  congenital  dis- 
location of  the  hip  three  times.^* 

(2)  Congenital  Character. 

The  arguments  for  the  congenital  character  of  these  dislocations 
of  the  head  of  the  radius  are: 

(i)  Discovery  of  the  condition  early  in  infancy,  without  preceding 
trauma. 

(2)  The  fact  of  being  bilateral,  although  Bartels"*  reports  a  bilateral 
dislocation  of  the  head  of  the  radius  in  a  boy,  acquired  by  pushing  a 


110  ORIGINAL  ARTICLES. 

heavy  cart,  and  Pungaud'*    reports  an  instance  in  which  both  radial 
heads  were  dislocated  by  violent  parturition. 
C3)   Concurrence  of  other  deformities. 

(4)  Inheritance. 

(5)  Pronounced  bone  changes;  but  bone  fusion,  similar  to  that 
occurring  in  the  cases  of  dislocations,  is  reported  without  dislocation 
by  Drenkhahn'^  (one  case),  JoachimstaP®  (three  cases),  Kiimmell" 
(three  cases,  one  bilateral),  and  Hamilton**  (one  case,  bilateral.) 

(6)  Greater  mobility  than  to  be  expected  in  acquired  dislocation. 

Upon  applying  these  arguments  to  the  51  cases  reported  as  con- 
genital, it  is  seen  that  the  congenital  character  of  some  is  more  or  less 
in  doubt,  judging  by  the  evidence  presented.  In  many  of  these  cases, 
however,  the  reports,  if  full,  would  probably  confirm  the  assertions 
of  the  respective  authors,  and,  on  account  of  the  difficulty  of  making 
a  satisfactory  standard  for  discrimination,  and  on  account  of  the  large 
number  of  the  cases  that  are  congenital  beyond  reasonable  doubt,  it 
has  been  thought  wise  to  include  all  the  51  reported  cases  in  compiling 
the  summary. 

(3)  Etiology. 

Blumenthal  refers  the  lesion  to  the  pronated  position  of  the  fetal 
elbow  in  human  gestation  and  the  special  exposure  of  the  head  of  the 
radius  in  this  position  to  injury  dependent  upon  deficient  liquor  amnii. 
This  would  account  for  the  usual  limitation  of  supination  in  these  cases, 
as  well  as  in  the  cases  of  congenital  interference  with  supination  with- 
out luxation.*® 

Ambard^^  refers  his  case  (Number  46)  to  congenital  syphilis,  and 
Bottomley**  reports  two  cases  of  Cotton's  in  which  congenital  syphilis 
produced  acquired  dislocation  of  the  head  of  the  radius  similar  to  the 
congenital  dislocations. 

Heredity  appears  to  be  operative  in  Pye-Smith's,  Abbott's,  and 
Blumenthal's  cases  (Numbers  9,  33,  34,  35,  36,  37,  38,  39,  and  44). 
In  the  seven  cases  of  Abbott's,  which  cover  four  generations  in  one 
family,  the  individual  transmitting  the  lesion  was  only  once  himself  or 
herself  subject  to  it. 

Hamilton**  classifies  the  theories  of  causation  of  congenital  dislo- 
cations in  general  as  follows : 

(i)   Physiological:  original  or  developmental  defect. 

(2)  Pathological:  contraction,  paralysis,  lax  ligaments,  hydrathro- 
sis,  or  some  other  diseased  condition  of  the  joint. 

(4)  Treatment. 

Four  operated  cases  are  reported: 

(i)  Complete  excision  of  the  elbow  in  Mitscherlich's  case  (Number 
7)  by  Langenbeck,  for  relief  of  great  limitation  of  flexion  and  perma- 
nent supination,  in  a  double  forward  dislocation.  The  result  was  not 
observed,  as  the  patient  died  shortly  after  operation. 


CONGENITAL  LUXATION  OF  RADIAL  HEAD  111 

(2)  Excision  of  radial  head  only  and  manipulations,  in  Bessel- 
Hagen's  case  (Number  26)  of  backward  dislocation,  for  relief  of 
pronated  and  semiflexed  position  and  limitation  of  all  motions.  Result, 
one  year  after  operation:  normal  motions. 

(3)  Excision  of  radial  head  and  distal  end  of  ulna,  and  osteotomy  of 
shaft  of  radius,  in  Bonnenberg*s  case  (Number  i)  of  forward  luxa- 
tion, for  limited  extension  and  permanent  supination.  The  lower  end 
of  the  ulna  was  excised  because  rotary  motion  was  found  to  be  impos- 
sible without  this  excision.  The  shaft  of  the  radius  was  divided  to 
straighten  the  arm.  The  result  was  free  extension  and  flexion  and 
a  position  of  pronation,  but  no  rotary  motion. 

(4)  Excision  of  radial  heads  and  manipulations,  in  LaFerte's 
bilateral  case  (Number  50)  of  forward  luxation,  for  permanent  exten- 
sion and  pronation.  Result  two  years  after  operation :  passive  but  no 
active  flexion,  and  no  supination. 

In  one  of  the  cases  reported  by  Bottomley,**  of  acquired  backward 
luxation  but  similar  to  the  congenital  type,  excision  of  the  heads  of  the 
radii  greatly  improved  the  mobility,  which  had  been  restricted  in  all 
directions. 

Thus  in  two  of  the  three  cases  of  congenital  luxation  in  which  the 
head  of  the  radius  was  excised,  free  active  flexion  and  extension  was 
obtained,  and  in  the  third  case  passive  flexion  was  obtained.  Rotation, 
however,  was  restored  to  only  one  of  these  three  cases,  though  in  one 
of  the  other  two  the  preferable  position  of  pronation  was  substituted 
for  that  of  supination. 

In  none  of  the  operated  cases  was  there  bone  fusion,  complicating 
the  luxation. 

v.— CONCLUSIONS. 

Nearly  two-thirds  of  the  cases  of  congenital  luxation  of  the  head 
of  the  radius  are  male. 

Equally  common  on  the  right  and  left  sides. 

The  commonest  direction  of  luxation  is  backward;  forward  luxa- 
tions nearly  as  common ;  outward  luxations  only  once  in  eight. 

In  nearly  all  of  the  combined  cases,  mobility  is  more  or  less 
restricted ;  but  in  half  the  outward  luxations,  mobility  is  free.  Supina- 
tion is  the  motion  most  often  limited ;  extension,  next  most  often.  In 
backward  luxations,  flexion  is  the  motion  most  often  free;  while  in 
forward  luxations,  extension  is  the  motion  most  often  free. 

Elongation  of  the  proximal  end  of  the  radius  is  present  in  three- 
quarters  of  the  cases,  and  is  about  equally  frequent  in  the  luxations 
in  the  diflFerent  directions. 

Bone  fusion  of  the  upper  parts  of  radius  and  ulna  present  in  one 
third  of  the  cases.  In  all  the  cases  with  fusion,  there  is  no  or  almost 
no  rotary  motion,  and  the  forearm  is  pronated  or  semipronated. 

In  nearly  half  of  the  cases,  there  is  some  other  deformity,  oftenest 
partial  deficiency  of  ulna  or  radius. 

Congenital  luxation  of  the  head  of  the  radius  is  very  rare. 


112  ORIGINAL  ARTICLES 

The  congenital  character  of  some  of  the  fifty-one  reported  cases  is 
open  to  doubt. 

The  factors  to  be  considered  in  etiology  are  the  special  embryology 
of  the  elbow,  congenital  syphilis,  heredity,  and  the  conditions  leading 
to  congenital  luxations  in  general. 

Excision  of  the  head  of  the  radius  is  indicated  by  considerable 
restriction  of  flexion  or  extension  in  uncomplicated  cases;  doubtful, 
in  cases  with  only  rotary  motion  restricted;  probably  cc«itraindicated, 
in  cases  with  practically  free  flexion  and  extension  but  permanent 
pronation  and  bone  fusion. 

REFERENCES. 

*  Powers,  C.  A. :    The  Journal  of  the  American  Medical  Association,  1903,  XLI, 

page  165. 
'  Blumenthal,  M. :  Zcitschr.  f.  orthop.  Chir.,  1904,  XII,  i  u.  2  Heft,  S.  181. 
'  Bonneberg :  Zcitschr.  f.  orthop.  Chir.,  1893,  II,  page  376. 

*  Abbott,  F.  C. :  "Transactions  of  the  Pathological  Society  of  London,"   1891-2, 

XLIII,  page  129.    Also:  Lancet,  1892,  page  800. 

*  Giirlt :    Beitrdge  zur  Vcrgleich.  path.  Anat.  der  Gelenkrankheiten,  1853,  page 

317,  Dupuytren's  case.    Through  Bonnenberg. 
Stimson,  L.  A. :  "Treatise  on   Dislocations,"   1888,  page  349,   same    (Dupuy- 
tren's) case. 

*Malgaigne,  J.  F. :  Die  Knochen-briiche  u.  Verrenkungen,  1856,  Band  II,  page 
631,  from  Dupuytren's  oral  report.     Through  Bonnenberg. 

"Servier:  Gas.  Hebdom.  de  Med.  et  de  Chir.,  1872,  IX   (second  series),  page 
214. 

"Herskovitz,  L. :     Wien.  med.  Presse,  1888,  XXIX,  page  217.     Through  Bon- 
nenberg. 

'Humphrey:  Med.  Chir.  "Transactions,"  XLV,  page  296.    Through  Stimson. 

'"  Mitscherlich:  Archiv.  f.  klin.  Chir.,  1865,  VI,  page  218.    Through  Stimson. 

"  Allen :  Glasgow  Medical  Journal,  1880,  XIV,  page  44.    Through  Stimson. 

"Pye-Smith:  Lancet,  1883,  II,  page  993.    Through  Stimson. 

*'  Phillips :  British  Medical  Journal,  I,  page  773.    Through  Stimson. 

"Heele:  Lancet,  1886,  II,  page  249.    Through  Stimson. 

"  Machenhauer :  Centralblatt  f.  Chir.,  XIX,  Nr.  13.    Through  Bonnenberg. 

"Adams,  R. :    "The  Cyclopedia  of  Anatomy  and  Physiology,"  1839,  H,  page  75. 
(Powers.) 
Also:  Dublin  Journal  of  Medical  Science,  Volume  XVII.     Through  Bonnen- 
berg. 

"  Deville,  A. :  Bui.  de  la  Soc.  Anatom.  de  Paris,  1849,  XXIV,  page  153.    Through 
Bonnenberg. 

"Senftleben:     Archiv.    f.    path.    Anat.    von    Virchotc,    1869.    XLV,    page    303. 
Through  Bonnenberg. 

'•■  Cruveilhier,  J. :   "Traite   d'Anat.   Path.   Generale,"   1849,   page  479.     Through 
Bonnenberg. 

*®  Bessel-Hagen,  F. :  Ueber  Knochcn  u.  Gelenkanomalien,  Laugcnbeck's  Archiv. 
f.  klin.  Chir.,  1891,  XLI,  page  420.     Through  Bonnenberg. 

"  Smith,  R.  W. :  Dublin  Quarterly  Journal  of  Medical  Science,  1850,  X.  Through 
Bonnenberg. 

*' Smith,  R.  W. :  Dublin  Quarterly  Journal  Medical  Science,  1852,  XII,  page  208. 
Also:  Proceedings  of  the  Pathological   Society  of  Dublin,  1841-50,  I,  part  2. 
page  185. 


LABOR  DURING   SECOND  STAGE.  113 

"•Toppich:  "Beitrag  zur  Kenntniss  der  angeborenen  Luxationen  des  Capitellum 
Radii,"  1888.     Through  Bonnenberg. 

••Leisrink:  Deutsch.  Zeitschr,  f.  Chir.,  1873-4,  IV,  page  16.  Through  Bonnen- 
berg. 

"Voigt:  Wagner's  Archiv.  f.  Heilkunde,  1863,  IV,  Seite  26.  Through  Bon- 
nenberg. 

*•  Schmid :   Zeitschr.  f.  orthoped,  Chir.,  1893,  Band.  II.    Through  Blumenthal. 

"  Ambard:  Rev.  d'Orthop.,  1901,  II  (second  series),  page  173,    Through  Powers. 

*•  Bergtold,  W.  H. :  Annals  of  Surgery,  1891,  XIV,  page  370.     Through  Powers. 

*•  Hamilton :  'Tractures  and  Dislocations,"  Philadelphia,  1880,  sixth  American 
edition,  page  888. 

••Guerin:  "Recherches  sur  les  Luxations  Congenitales,"  Paris,  1841.  Through 
Hamilton. 

•*  Present  article. 

"  Stimson,  L.  A. :  "Fractures  and  Dislocations,"  1900,  third  edition,  page  463. 

**  Kronlein :  Deutsche  Chirurgie,  XXVI,  page  82. 

**  Bradford  and  Lovett :  "Orthopedic  Surgery,"  New  York,  1905,  third  edition, 
page  479- 

"Bartels:  Archir.  f.  klin.  Chir,,  1874,  XVI,  page  643.    Through  Stimson. 

••  Pungaud :  "Diet.  Encycloped.  des  Sc.  Med.,"  page  606.     Through  Stimson. 

"  Drer>khahn :  Zeitschr.  f.  orthop,  Chir.,  1903,  II.     Through  Blumenthal. 

"  Joachimstal :  Die  angeborenen  Verbildungen  der  obern  Extremitdten,  1900, 
Seite  17.    Through  Blumenthal. 

*  Kiimmell :  Die  Missbildungen  der  Extremitdten,  Biblioth.  med.,  Band.  III. 
Through  Blumenthal. 

**Drenkhahn:  Deut.  milit'drdrstl.  Zeitschr.,  1905,  Heft  6.  Abstract  Deut.  med. 
IVochenschr.,  1905,  July  6. 

**  Discussion  of  Powers*  paper. 

**  Quoted  by  E.  M.  Moore,  in  "Reference  Handbook  of  the  Medical  Sciences," 
Philadelphia,  1886,  II,  page  485. 

"  Riss,  Raymond :  "Die  angelborene  Luxation  des  Radius,  Franzosische  Disser- 
tationen,"  Paris,  1902.  Abstract  in  Centraiblatt  f.  Gynak.,  1903,  38,  page 
1 150. 

"  Hamilton  S :  "Case  of  Congenital  Synostosis  of  Both  Upper  Radio-Uluar  Ar- 
ticulations," British  Medical  Journal,  November  18,  1905,  Number  2342, 
page  1327. 


CONDUCT  OF  LABOR  DURING  THE  SECOND  STAGE.* 

By  WILLIAM  H.  .MORLEV,  Ph.  B..  .M.  D.,  Ann  Arbor,  Michigan. 

DBMONSntATOK  OF  OBSTBTRICS  AND  GVNBCOLOGV   IN  THB  UNIVBRSITY   OF   MICHIGAN 

An  apology  is  due  to  members  of  the  Society  for  bringing  this 
hackneyed  subject  to  your  notice,  but  my  recent  experience  and  the 
vast  amount  of  material  at  my  command  during  two  years  abroad  may 
to  some  extent  mitigate  my  extreme  audacity  in  presenting  this  theme 
for  your  consideration. 

It  is  needless  to  tell  you,  but  nevertheless  important  to  define  at  the 
outset  the  various  stages  of  labor.  Labor  is  arbitrarily,  and  for  matter 
of  convenience,  divided  into  three  stages.  The  first  dates  from  the 
time  the  parturient  commences  to  have  labor  pains  until  the  cervix 

♦Read  before  the  Washten.aw  County  (Ann  Arbor)  Medical  Society. 


114  ORIGINAL  ARTICLES. 

is  fully  dilated.  This  condition  of  full  dilatation  is  determined  when 
the  patient  begins  to  bear  down.  The  second  stage  extends  from  full 
dilatation  of  the  os  to  birth  of  the  child,  and  the  third  and  last  stage 
from  delivery  of  the  child  until  the  birth  of  the  placenta  and  mem- 
branes. In  the  first  stage  the  pains  may  be  so  severe  as  to  compel  the 
parturient  to  take  her  bed,  but  as  a  rule  she  is  up  and  about.  She 
should,  however,  be  put  to  bed  soon  after  the  membranes  rupture,  or 
at  the  beginning  of  the  bearing-down  pains.  This  is  especially  impor- 
tant in  multipara  as  the  second  stage  is  usually  of  short  duration ;  often 
lasting  but  five  or  ten  minutes  from  complete  dilatation  of  the  cervix 
to  birth  of  the  fetus. 

I  take  it  for  granted  that  you  have  had  your  patient  under  sur- 
veillance for  some  months  previous  to  the  beginning  of  the  first  stage, 
and  have  made  all  necessary  arrangements  for  the  confinement.  The 
external  examination,  diagnosis  of  presentation  and  position,  clipping 
of  vulval  hair,  aseptic  preparation  of  external  genitalia,  dressings, 
et  cetera,  have  all  been  made.  As  the  second  stage  is  short  in  multipara, 
it  is  well  during  the  first  stage  to  have  the  bed  in  readiness  for  recep- 
tion of  the  parturient,  and  it  is  about  its  preparation  that  I  wish  next 
to  speak. 

Preparation  of  the  Bed, — ^A  high  iron  bed  is  the  best,  but  as  often 
occurs  in  private  practice,  the  physician  may  be  compelled  to  use  the 
low  double  bed.  In  either  case  its  preparation  is  the  same.  The 
accoucheur  stands,  or  is  seated  at  the  left  side.  This  fact  should  be 
borne  in  mind  when  the  bed  and  accessories  are  made  ready  for  the 
confinement.  A  rubber  sheet  of  sufficient  length  and  width  should  be 
placed  to  cover  the  entire  mattress.  Over  this  an  ordinary  sheet. 
Then  a  second  rubber  sheet  of  sufficient  size  to  cover  the  middle  third 
of  the  bed  and  on  top  of  this  latter  another  sheet.  These  two  latter, 
that  is,  the  rubber  and  the  muslin  sheet,  should  be  so  arranged  as  to 
allow  easy  removal  after  completement  of  the  third  stage.  The  puer- 
peral patient  will  then  recline  upon  the  large  rubber  and  muslin  sheet 
mentioned  above.  In  the  bed  thus  prepared  with  its  double  layer  of 
rubber  and  muslin  sheets,  the  parturient  is  placed,  preferably  on  her 
left  side.  Underneath  her  buttocks,  which  are  brought  as  far  as  pos- 
sible to  the  left  edge  of  the  bed,  may  be  placed  a  Kelly  pad,  with  the 
apron  extending  over  the  edge  into  a  bucket  or  pan,  or  what  I  per- 
sonally prefer,  a  sterile  pad  of  gauze  and  cotton  placed  under  the 
buttocks  to  receive  whatever  discharge  may  come  from  the  vulva 
during  the  second  stage.  To  prevent  contamination  from  the  hips  of 
the  patient,  l^gings,  which  have  been  previously  sterilized,  are  drawn 
on  and  tied  high  up  on  the  hips.  The  buttocks  are  covered  with  a 
sterile  sheet,  and  another  is  placed  on  the  bed  in  front  of  the  posterior 
buttock. 

Examination  During  the  Second  Stage. — ^Vaginal  examinations, 
except  in  rare  cases,  are  to  be  condemned.  External  abdominal  exam- 
ination between  pains  to  denote  progress  in  descent,  or  the  extent  of 


LABOR  DURING  SECOND  STAGE.  116 


i 


engagement   of    fetal    head,    can    be    made    as    often    as.  necessary.  I 

Control  of  fetal  activity  by  auscultation  of  fetal  heart  from  time  to 
time  is  also  a  good  procedure.  But  constant  and  repeated  vaginal 
examinations  cannot  be  too  strongly  deprecated.  The  great  risk  of 
.infection,  and  the  small  amount  of  additional  information  to  be  gained, 
do  not,  in  most  cases,  warrant  such  a  drastic  procedure. 

Delivery. — When  the  vulva  begins  to  gape  or  the  perineum  com- 
mences to  bulge,  it  is  time  for  the  accoucheur  to  disinfect  his  hands 
and  arms  with  soap  and  water,  and  then  with  bichloride.  A  long-sleeved  ' 
gown  and  rubber  gloves,  both  previously  sterilized,  are  put  on.  Then 
the  sterile  sheet  is  placed  over  the  buttocks,  and  another  on  the  bed  in 
front  of  the  posterior  buttock.  It  is  seen  that  the  parturient  is  on  her 
side,  preferably  the  left,  in  a  modified  Sims  position  with  her  buttocks 
near  the  left  side  of  the  bed.  On  a  table  near-by  covered  with  a  sterile 
sheet  are  placed  two  sterile  basins,  one  containing  sterile  water,  and  one 
bichloride  (one  to  two  thousand).  In  both  solutions  are  placed  small 
pledgets  of  sterile  cotton.  The  table  should  also  contain  a  basin  with 
tape  for  cord,  scissors,  and  a  catheter,  all  of  which  have  been  previously 
sterilized.  Instruments  for  perineal  repair,  obstetrical  forceps,  et  cetera, 
are  boiled  and  kept  in  readiness.  A  blanket,  or  preferably  a  padded 
box,  over  which  a  sterile  bag  with  purse  string  suture  is  drawn,  is  put 
between  the  knees  of  the  patient.  The  left  hand  of  the  physician  is 
placed  between  the  thighs  of  the  parturient  and  brought  around  in  such 
a  way  as  to  cover  the  vulva.  The  right  hand  is  free  to  wipe  away 
fecal  matter  discharged  from  the  rectum  with  the  pledgets  of  cotton 
soaked  in  bichloride  or  sterile  water,  and  to  protect  the  perineum 
during  the  pains.  In  this  way  the  accoucheur  has  the  fetal  head  and 
perineum  under  complete  control. 

Use  of  an  Anesthetic. — The  question  naturally  arises,  shall  an  anes- 
thetic be  employed  ?  In  few  cases,  confinement  may  take  place  without 
anesthesia.  It  is  better  both  for  mother  and  child  not  to  administer 
an  anesthetic  during  the  first  stage.  It  often  becomes  necessary,  how- 
ever, in  the  second  stage  to  give  the  parturient  a  few  whiffs  of  chloro- 
form to  ease  the  pain,  and  at  the  same  time  save  the  perineum.  Do 
not  slug  your  patients  with  chloroform.  It  is  not  necessary.  It  will 
often  unnecessarily  prolong  labor,  and  prevent  later  contractions  of  the 
uterus.  When  a  pain  starts  a  few  drops  of  chloroform  on  an  Esmarch 
inhaler  will  prove  sufficient,  and  the  cone  should  be  removed  at  the 
completion  of  the  pain.  A  small  amount  of  the  anesthetic  given 
synchronous  with  pains  will  have  the  desired  effect.  There  is  little  to 
be  said  in  the  choice  of  an  anesthetic.  Qiloroform  has,  since  its 
discovery  in  1847,  by  Sir  James  Simpson,  been  considered  the  ideal 
lying-in-room  anesthetic.  Recent  investigations  with  cocaine  injected 
intraspinously,  with  scopolamine,  and  other  local  anesthetics,  have 
shown  some  good  results,  and  much  is  claimed  by  their  adherents. 
The  results  are  too  meager,  however,  to  allow  them  to  supplant  chloro- 
form. 


116  ORIGINAL    ARTICLES. 

Protection  of  the  Perineum, — As  was  mentioned  above,  the  par- 
turient is  placed  on  her  left  side  in  a  semiprone,  or  a  modified  Sims 
position,  with  her  buttocks  near  the  left  edge  of  the  bed.  The  thighs 
are  held  apart  with  the  padded  box,  over  which  a  sterile  bag  has  been 
drawn.  The  obstetrician  stands  with  his  left  side  against  the  edge 
of  the  bed.  His  left  arm  is  put  around  between  the  thighs,  so  that 
the  left  hand  may  easily  cover  the  vulva  and  control  the  fetal  head. 
The  right  hand  is  free  to  protect  the  perineum,  and  keep  the  parts 
cleanly  and  aseptic  with  the  pledgets  of  cotton,  dipped  alternately  in 
sterile  water  and  bichloride  solution.  At  the  commencement  of  a 
pain  the  left  hand  allows  the  head  to  slowly  advance  upon  the  already 
somewhat  distended  perineum.  The  right  hand,  upon  whose  palmar 
surface  is  placed  a  pledget  of  cotton  wet  with  bichloride,  is  so  placed 
that  the  thumb  and  first  finger  span  the  fourchette.  The  perineum 
is  grasped  on  either  side  and  slightly  folded.  As  the  head  advances, 
controlled  by  the  left  hand,  the  perineum  is  allowed  to  gradually  receive 
the  force  of  the  advancing  head,  so  that  before  completion  of  the  pain 
the  perineum  has  received  the  full  impact  of  the  head  as  rapidly  or  as 
slowly  as  the  physician  desires.  This  can  be  repeated  until  it  is  thought 
the  perineum  is  fully  dilated.  I  have  by  this  method  held  the  head 
back  with  my  left  hand,  when  removal  would  have  allowed  the  head 
to  slip  over  the  perineum,  which  I  did  not  deem  fully  stretched.  When, 
however,  the  perineum  is  fully  dilated  and  extension  has  taken  place 
to  such  a  degree  that  the  forehead  is  visible  at  the  fourchette,  the 
tension  of  the  left  hand  between  a  pain  be  gradually  relieved,  and 
birth  of  the  head  is  allowed  to  take  place.  This  is  done  in  the  follow- 
ing way :  the  occiput  is  well  out  from  under  the  arch  of  the  pubes,  and 
the  left  hand  gradually  brings  about  increased  extension  of  the  head 
by  light  traction  on  the  brow.  The  right  hand,  whose  thumb  and 
forefinger  rim  the  fourchette,  presses  lightly  but  firmly  on  the  perineum 
and  follows  it  down  over  the  brow,  face,  and  chin.  External  rotation, 
or  restitution,  immediately  takes  place. 

Cord  About  the  Neck. — Examination  is  at  once  made  to  see  if  the 
cord  is  about  the  neck.  When  such  is  the  case  it  is  at  once  reduced 
by  slight  traction,  and  slipped  over  the  head.  It  may  be  necessary  to 
clamp  the  cord  when  reduction  is  impossible.  But  these  are  rare 
instances,  as  it  is  only  in  cases  where  the  cord  is  unusually  long  that 
it  becomes  wound  around  the  neck,  and  from  its  increased  length  is 
easily  reducible. 

Delivery  of  Shoulders, — As  soon  as  the  head  is  born  the  patient  is 
placed  in  the  dorsal  position.  The  head  is  grasped  with  both  hands  in 
such  a  way  that  the  palmar  surfaces  lie  next  to  the  lateral  surfaces 
of  the  head,  and  just  anterior  to  the  parietal  bones.  Slight  pressure 
is  made  downward  and  backward,  until  the  anterior  shoulder  appears 
well  out  from  under  the  arch  of  the  pubes.  The  head  is  then  lifted 
upward  to  allow  the  posterior  shoulder  to  glide  over  the  perineum. 
Delivery  of  the  body  usually  follows  rapidly,  but  to  prevent  tear  of 


LABOR  DURING   SECOND  STAGE.  117 

the  perineum  the  hands  should  still  be  kept  on  the  head.  In  addition 
the  forefingers  are  lightly  inserted  in  the  child's  axillae,  and  tjhe  fetus 
carried  upward  and  forward  over  the  mother's  abdomen.  In  this  way 
the  child  follows  the  curve  of  Carus  and  its  weight  is  not  allowed  to 
tear  the  already  greatly  distended  perineum.  Care  should  be  taken 
not  to  use  traction  with  the  forefingers  which  have  been  placed  in  the 
child's  axillae.  Stretching  of  the  brachial  plexus,  or  fracture  of  an 
arm  may  result.  The  tension  should  be  on  the  head,  but  to  prevent 
too  great  tension  and  the  slipping  of  the  hands  from  the  head,  the 
forefingers  are  placed  in  the  axillae.  • 

Ligation  of  the  Cord. — The  child  is  held  upward  by  the  lower  limbs 
and  a  parental  slap  made  on  the  buttock  to  expel  any  mucus  that 
may  lodge  in  the  posterior  pharynx  and  upper  respiratory  passages. 
A  vigorous  lusty  cry  will  denote  that  the  trachea  is  clear.  The  child 
is  then  placed  on  its  right  side  close  enough  to  the  mother  to  prevent 
traction  on  the  cord.  The  cord  is  grasped  and  pulsation  controlled. 
As  long, as  the  cord  pulsates,  it  is  not  tied.  When  pulsation  stops,  a 
narrow  tape  is  passed  around  the  cord  about  seven  centimeters  from 
the  child's  body,  and  securely  tied.  Another  is  similarly  placed,  and 
the  cord  ligated  on  the  maternal  side  about  three  centimeters  from  the 
first  ligation.  The  cord  is  then  laid  in  the  palmar  surface  of  the  left 
hand  in  such  a  way  that  the  hand  is  interposed  between  the  child's 
abdomen  and  the  ligatures.  The  cord  is  cut,  all  bleeding  stopped,  and 
the  child  handed  to  the  nurse. 

A  bed  pan  is  placed  under  the  patient's  hips  for  reception  of  the 
after-birth.  The  uterus  is  held  by  the  hand  of  an  assistant  or  nurse 
to  prevent  its  relaxation,  and  the  third  stage  begins. 

Use  of  Ergot. — So  much  has  been  written  about  the  use  of  ergot 
in  the  second  stage,  or  at  its  completion,  that  I  cannot  refrain  from 
saying  a  few  words  on  this  point.  Such  a  practice  need  only  be  men- 
tioned to  be  most  severely  condemned.  First,  it  is  never  indicated,  as 
slight  massage  of  the  fundus  uteri  will  control  any  slight  hemorrhage 
in  most  cases.  In  uncontrollable  hemorrhage,  first  remove  the  after- 
birth by  Crede's  method,  then  give  your  ergot.  Secondly,  ergot 
administered  in  the  second  stage  will  cause  the  uterus  to  contract 
down  upon  the  placenta  and  membranes,  and  cause  their  retention, 
whole,  or  in  part.  I  never  prescribe  ergot  in  the  third  stage  unless 
indicated,  and  am  not  a  firm  believer  in  its  employment  as  a  prophy- 
lactic. 

Repair  of  Perineum. — This  properly  belongs  to  the  third  stage,  but, 
should  a  tear  occur,  it  may  be  well  to  pass  the  silkwormgut  sutures  at 
the  end  of  the  second  stage  before  the  patient  comes  out  from  under 
the  anesthesia.  The  ends  can  be  held  with  hemostats  and  tied  after 
the  placenta  and  membranes  are  born.  This  does  away  with  a  second 
anesthetic.  Personally  I  prefer  to  let  patient  out  and  then  repair  any 
tear  at  end  of  the  third  stage.  A  few  whiflFs  of  chloroform  are  gen- 
erallv  sufficient. 


118  ORIGINAL  ARTICLES. 

Such  in  brief  is  the  method  I  have  adopted  in  the  conduct  of  labor 
in  the  second  stage.  I  do  not  claim  any  originality,  do  not  believe  I 
have  invented  anything  new.  Having  seen  a  good  many  different 
obstetricians,  and  studied  their  methods,  I  have  only  taken  what  I 
considered  to  be  their  best  points  to  form  one  of  my  own.  This  I 
have  endeavored  to  bring  to  your  notice  this  evening.  Just  one  point 
more ;  do  not  forget  that  labor  in  most  cases  is  a  normal,  physiological 
process,  and  any  unnecessary  meddling  may  transfer  it  from  the 
domain  of  physiology  to  the  realms  of  pathology.     DO  NOT  DO  IT! 


REMARKS  ON  LA  GRIPPE. 
By  JOHN  S.  CAULKINS,  M.D.,  Thornville,  Michigan. 

Personal  subjection  to  la  grippe  affords  the  most  certain  means  of 
obtaining  a  complete  and  intimate  knowledge  of  the  nature  and  results 
of  the  disease,  but  the  writer  has  not  l^een  permitted  the  opportunity 
of  study  from  the  standpoint  of  patient,  and  can  therefore  only  record 
what  has  been  observed  in  practice. 

Description  of  the  Disease. — It  is  difficult  to  classify  Russian  influ- 
enza under  any  name  that  will  imply  the  nature  of  the  disease.  The 
nearest  approach  possible  is  to  call  it  a  catarrhal  fever,  but  that  scarcely 
covers  the  ground,  for  many  cases — perhaps  a  third  of  the  total — show 
very  slight  catarrhal  symptoms.  We  might  almost  say  there  are  two 
distinct  forms  of  la  grippe — the  catarrhal  and  the  noncatarrhal.  In  the 
first  there  is  cough,  congestion  of  the  mucous  membranes  of  the  lungs, 
throat  and  head,  together  with  all  the  symptoms  of  a  severe  cold.  The 
other  is  a  break-bone  fever  without  the  catarrh.  The  two  have  some 
features  in  common,  the  fever  in  both  being  high,  and  the  pain  in  head 
and  back,  between^the  hips,  intense. 

Tliermometry  of  the  Disease. — Perhaps  there  is  no  other  affection 
in  which  the  fever  runs  higher,  not  excepting  malignant  scarlet  fever. 
It  is  a  scorching,  burning  fever.  It  is  not  so  high  now  as  formerly, 
when  it  was  common  to  record  104°,  in  cases  of  vigorous,  strong  boys 
105°  being  noted,  and  in  a  few  instances  even  registering  above  that 
high  point.  However,  seldom  will  much  more  than  103°  be  observed. 
No  low  temperatures  were  found  by  me  in  typical  unmixed  cases,  and 
r  think  there  are  none,  although  this  statement  may  be  criticized  in  the 
discussion  of  this  paper.  Some  may  say,  perhaps  all  may  unite  in 
saying,  that,  any  grade  of  fever  may  characterize  the  malady,  but  I 
have  expressed  my  belief,  and  when  every  source  of  error  is  eliminated 
I  think  the  statement  will  be  found  correct.  An  epidemic  of  gigantic 
proportions  necessarily  contemplates  a  great  number  of  other  diseases, 
among  which  may  be  mentioned  common  influenza,  which  is  always 
endemic  if  not  epidemic,  and  can  only  be  discriminated  from  la  grippe 
by  its  milder  type,  the  temperature  being  low.  Here  would  be  one, 
and  possibly  the  main,  source  of  error.  Another  would  lie  in  not 
accurately  observing  the  dividing  line  between  the  temperatures  of  la 


REMARKS  ON  LA  GRIPPE.  119 

grippe  and  its  numerous  sequels.  What  renders  my  opinion  probable 
is  the  fact  that  every  disease  has  its  own  thermometry  from  which  it 
does  not  vary  much.  This  point  is  sometimes  invaluable  in  differential 
diagnosis.  Who  ever  saw  a  low  temperature  in  measles  or  scarlet 
fever,  or  a  very  high  one  in  rotheln? 

Duration  of  the  Disease, — La  grippe,  according  to  my  observation, 
lasts  three  days.  If  the  attack  has  its  inception  on  Monday  morning 
the  patient  will  be  free  from  fever  on  Thursday  morning.  Of  course 
I  do  not  include  relapses  or  sequels.  These  are  not  la  grippe,  they  are 
conditions  that  succeed  it. 

Complications,  Relapses  and  Sequels, — Pneumonia  has  not  been 
observed  as  a  complication  by  me,  but  it  has  been  met  as  a  sequel. 
Bronchitis  is  a  frequent  complication,  so  are  congestion  of  the  lungs 
and  tonsillitis.  It  is  doubtful  if  there  is  any  real  relapse  of  la  grippe. 
I  should  as  soon  look  for  a  relapse  of  measles.  The  sequels  of  the 
disease  are  many,  some  immediate  and  some  remote.  The  immediate 
in  the  order  of  gravity  are  pneumonia,  nervous  prostration,  bronchitis, 
and  neuralgia.  Among  the  remote,  consumption  has  caused  death  in 
some  who  had  la  grippe  two  years  previously.  In  another  class  of 
cases  the  mischief  that  was  done  by  la  grippe  can  only  be  described  by 
saying  that  the  constitutions  of  the  subjects  were  wrecked  by  the 
disease. 

Tlie  Cause. — For  hundreds  of  years  there  has  been  great  speculation 
over  the  cause  of  this  disease.  Influenza  is  an  Italian  word  that  has 
been  used  in  the  English  language  until  it  is  naturalized  and  means 
simply  influence.  The  influence  of  what?  When  the  world  believed 
in  astrology,  it  was  thought  to  be  rained  down  by  certain  malign  stars 
in  conjunction  or  apposition,  or  whatever  the  phraseology.  That 
superstition  outgrown,  it  was  believed  to  be  caused  by  some  occult 
telluric  influence.  This  idea  has  been  promulgated  in  my  time  not 
only  with  regard  to  influenza  but  Asiatic  cholera  as  well.  The  Germans 
adopted  the  name  for  the  disease.  They  called  it  the  Nordische  or 
Russiche  influentz.  The  belief  in  an  influence  was  natural  enough  at 
that  time.  The  spectacle  of  so  many  falling  sick  at  once,  suggested 
the  idea  of  the  disease  being  sent  by  some  power  inimical  to  the  human 
race.  The  French  name  suggested  something  akin  to  the  same  idea; 
as  if  some  invisible  monster  had  suddenly  grasped  its  helpless  victim 
in  its  talons. 

La  grippe  is  an  essential  fever,  and  like  the  rest  of  its  class  can  have 
but  one  way  of  spreading,  and  that  is  by  the  reception  into  the  circula- 
tion of  its  own  contagium  virum,  the  living  microbe  or  fungus,  which 
causes  the  sharp  and  active  fermentation  in  the  blood,  so  characteristic 
of  the  disease.  It  would  be  more  correct  to  say,  which  is  the  disease. 
The  ptomaines  generated  during  this  fermentation  must  be  peculiarly 
poisonous,  for  the  extreme  prostration,  lassitude  and  pain  which  mark 
the  disease  are  out  of  all  relative  proportion  to  the  catarrhal  symptoms 
and  must  be  caused  by  these  poisons.     The  microbe  of  la  grippe  is  not 


120  ORIGINAL  ARTICLES. 

yet  identified,  or  at  least  observers  who  claim  to  have  discovered  it  do 
not  agree  in  its  description.  Pfeiffer,  the  son-in-law  of  Koch,  is  the 
latest  claimant,  and  the  confirmation  of  his  alleged  discovery  is  looked 
for  with  interest,  but  if  his  claim  is  not  confirmed,  nor  even  that  of  any 
other  observer,  we  may  rest  assured  that  the  microbe  is  in  waiting  to 
be  discovered. 

Pfeiflfer  is  connected  with  the  Berlin  Institute  for  Contagious  Dis- 
eases. His  conclusions  are  based  on  a  careful  study  of  thirty-one 
cases  of  la  grippe,  six  of  them  being  postmortems.  His  microbe  is  a 
minute  rod  or  bacillus  as  thick  as  that  of  mouse  septicemia  and  half  as 
long.  There  is  some  difficulty  about  culture  and  staining,  and  this  has 
misled  other  observers.  PfeiflFer  believes  that  other  observers  have 
seen  the  same  bacillus  but  have  described  it  as  a  micrococcus  because 
it  takes  the  stain  at  the  ends.  Kitasato  has  seen  and  described  the 
bacillus,  agreeing  essentially  with  Pfeiffer.  The  microbic  and  con- 
tagious nature  of  the  disease  is  admitted,  but  some  work  is  needed  to 
learn  just  how  the  contagium  virum  is  conveyed  from  one  to  another. 
In  all  probability  it  is  in  the  breath  of  the  patient,  and  perhaps  in  the 
secretion  of  the  skin. 

Treatment, — More  than  three-quarters  of  the  cases  of  la  grippe  are 
treated  at  home  in  a  variety  of  ways.  A  favorite  method  of  treatment 
is  to  take  a  dose  of  pills  and^drink  all  the  cider,  made  strong  with  red 
pepper,  one  can  hold.  The  other  quarter,  or  less,  that  the  doctor  sees 
are  mostly  complications  and  sequels  and  are  to  be  treated  symptomat- 
ically.  There  is  no  specific  for  the  disease.  It  is  a  good  plan,  if  the 
person  is  seen  during  the  attack,  to  give  a  cathartic — say  a  dose  of 
compound  cathartic  pills.  The  operation  will  materially  relieve  the 
intense  pain  in  the  head,  and  awaiting  that,  a  dose  or  two  of  acetanilid 
will  afford  much  relief.  We  ought,  however,  to  select  our  cases  for 
this  treatment.  The  effect  is  too  depressant  sometimes  for  safety. 
Now  and  then  a  patient  will  sweat  so  profusely  that  it  is  really  alarm- 
ing. We  should  be  very  careful  with  acetanilid  in  la  grippe.  Still,  I 
have  given  it  to  small  children  and  once  to  a  man  eighty-two  years  of 
age,  with  excellent  effect.  Antipyrine.  which  was  so  extensively  used 
two  years  ago,  seems  to  have  dropped  out  of  focus.  Beyond  a  doubt 
much  harm  has  been  done  with  that  drug.  That  class  of  remedies,  in 
such  a  prostrating  disease  as  la  grippe,  ought  to  be  used  with  great 
caution.  After  the  bowels  are  evacuated  opiates  are  to  be  preferred  to 
them  if  the  pain  in  head  and  back  continues.  Quinine  is  not  a  specific 
in  la  grippe.  It  neither  shortens  its  course  nor  does  it  afford  any -relief 
so  far  as  1  have  observed. 

Notwithstanding  treatment  the  malady  has  its  course  to  run  and  the 
function  of  the  doctor  is  to  see  that  the  course  runs  normally  and  to 
obviate,  if  possible,  any  threatened  mischief.  Avoidance  of  all  exposure 
for  a  week  after  the  disease  subsides  is  of  the  utmost  benefit  to  the 
patient.  It -is  carelessness  in  this  particular  that  makes  work  for  the 
doctor. 


WASHTENAW  COUNTY  MEDICAL  SOCIETY.  121 

TRANSACTIONS. 


WASHTENAW  COUNTY  MEDICAL  SOCIETY. 


REGULAR  MEETING,  ANN  ARBOR,  DECEMBER  14.  iQ^S- 
The  President,  JOHN  A.  WESSINGER.  M.  D..  in  the  Chair. 
Reported  by  JOHN  WILLIAM  KEATING.  M.  D..  Secretary. 

REPORTS  OF  CASES. 
AN  UNUSUAL  CASE  OF  DYSMENORRHEA. 

Doctor  James  B.  Wallace:  A  single  lady,  aged  twenty-one 
years,  living  at  home,  came  to  me  March  18,  1905,  complaining  of 
severe  attacks  of  dysmenorrhea.  She  is  the  second  daughter  in  a  family 
of  four  girls.  Her  mother,  now  aged  forty-five,  w-as  troubled  with 
severe  menstrual  pains  when  a  girl  and  attributed  the  patient's  affection 
to  an  hereditary  influence.  The  patient's  sisters  have  no  more  pain  at 
the  menstrual  periods  than  is  considered  normal.  The  jnother  is  a 
healthy  woman  and  her  confinements  were  normal  and  easy.  The 
family  are  all  in  good  health  except  the  patient,  and  she  has  never 
experienced  any  trouble  except  at  the  menstrual  periods,  and  the  fact 
that  she  is  subject  to  a  very  obstinate  constipation. 

The  patient  has  had  the  ordinary  diseases  of  childhood,  and  no 
other  sickness  nor  disease.  She  was  regarded  to  be  perfectly  well  up 
to  the  age  when  she  would  ordinarily  begin  to  menstruate.  About  the 
time  she  was  thirteen  or  fourteen  years  of  age  her  mother  noticed  that 
she  was  nervous  and  feverish,  and  oftentimes  choreic.  This  she  attrib- 
uted to  the  approaching  catamenia  and  did  not  pay  much  attention  to  it. 
The  nervous  disturbances  did  not  disappear  although  the  mother  thinks 
they  did  not  increase  as  time  went  on.  Menstruation  was  not  estab- 
lished, however,  until  the  patient  was  seventeen  years  old,  and  at  that 
time  she  was  almost  in  convulsions  from  the  pain.  The  girl  had  no 
medical  treatment  during  the  years  of  approaching  maturity,  except 
some  patent  nerve  nostrum,  Lydia  Pinkham's  vegetable  compound,  and 
Porter's  pain  king. 

After  the  menstrual  function  was  established,  the  patient  felt  better, 
except  a  few  days  before  and  during  the  menstrual  week.  Her  nervous- 
ness and  apprehension  did  not  abate,  but  she  began  to  await  the  dreaded 
period  with  feelings  approaching  hysteria.  The  pain  just  before  the 
flow  began  was  so  severe  that  for  a  few  months  before  the  patient  came 
under  my  observation,  she  had  gone  into  convulsions  at  those  times. 
She  was  quite  irregular,  sometimes  going  seven  to  eight  weeks,  and  at 
other  times  menstruating  as  often  as  every  two  or  three  weeks. 

The  period  in  February,  1905,  was  the  worst  she  ever  had,  and  the 
mother  told  me  that  she  had  much  more  severe  pain  than  any  woman 
she  had  ever  seen  in  labor.  The  reason  she  had  never  had  treatment 
for  her  trouble  was  an  implicit  faith  in  patent  medicines  on  the  part  of 


122  ORIGINAL  ARTICLES. 

her  mother  and  a  somewhat  exaggerated  dread  of  exposure  on  her  part. 
On  March  i8,  1905,  the  mother  came  to  consult  me  about  her  but 
dtd  not  bring  the  patient  along.  I  obtained  the  facts  of  this  history  as 
I  have  given  them,  from  her  at  that  time.  I  plainly  told  the  mother 
that  she  must  bring  the  patient  and  be  prepared  to  have  her  examined 
if  need  be,  before  I  could  tell  her  the  cause  of  her  trouble.  Several 
days  later  they  came  to  my  office.  The  girl  was  a  well-nourished,  and 
healthy-looking  lass,  and  did  not  show  the  signs  of  the  nervous  disturb- 
ances through  which  she  had  gone.  A  careful  and  extended  physical 
examination  showed  that  there  was  nothing  wrong  with  any  of  the 
organs  of  the  body  except  the  site  of  the  trouble,  plus  the  chronic  consti- 
pation, and  a  peculiar  drawing  or  bearing  down  feeling  during  the  act 
of  defecation  and  sometimes  also  while  passing  urine.  I  then  told  the 
mother  that  unquestionably  there  was  some  abnormal  position  of  the 
uterus  and  that  I  would  make  an  examination.  The  patient  consented 
and  the  cause  of  her  trouble  was  soon  apparent.  The  nymphae  were 
very  long  but  as  the  girl  was  scrupulously  cleanly  there  were  no  irri- 
tants IcKjged  there.  The  hymen  was  normal  but  very  tight,  and  I  found 
much  difficulty  to  introduce  the  finger  even  through  the  hymen  without 
producing  much  pain.  Finally  this  was  eccomplished  and  I  found  the 
vagina  apparently  smaller  than  the  hymen.  It  appeared  so  small  that 
I  had  to  abandon  the  use  of  the  finger  and  make  exploration  with  the 
sound.  The  vagina  was  of  normal  depth  and  I  could  easily  touch  the 
OS  uteri  with  the  sound.  While  attempting  to  withdraw  the  sound 
I  observed  that  the  point  caught  upon  something  which  I  could  not 
make  out.  Examination  per  rectum  showed  a  retroflexion  of  the  third 
degree.  A  speculum  could  not  be  introduced  into  the  vagina  so  I 
tried  a  branching  ear  speculum  which  showed  the  cause  of  the  trouble. 
Just  inside  the  hymen  was  a  septum  extending  from  the  anterior  to  the 
posterior  wall,  the  whole  length  of  the  vagina  and  dividing  it  longitu- 
dinally into  two  nearly  equal  parts.  I  advised  its  immediate  removal. 
This  was  agreed  to,  but  the  girl  would  not  permit  my  bringing  another 
physician  to  give  the  anesthetic.  The  next  day  I  went  to  the  patient's 
home,  where  I  made  ready,  gave  the  anesthetic,  and  dilated  the  vagina. 
I  found  that  the  os  uteri  was  freely  movable ;  a  sound  could  be  passed 
into  it  from  either  passage.  The  unusual  part  of  this  case  consisted 
in  the  part  of  the  septum  near  the  os  uteri.  For  about  one  inch  in 
length,  there  was  a  wedge-shaped  portion, — the  base  impinging  against 
the  OS — the  apex  becoming  continuous  with  the  membranous  septum. 
This  wedge-shaped  portion  was  firm  and  contained  muscular  tissue. 
I  removed  the  septum,  controlling  the  hemorrhage  with  spray  of  adre- 
nalin; sewed  up  the  wounds  with  chromacized  catgut;  replaced  the 
retroverted  uterus:  packed  the  vagina  with  gauze;  catheterized  the 
bladder,  and  permitted  the  patient  to  come  out  from  the  anesthetic. 
When  awake  she  said  she  had  no  pain  and  felt  all  right.  I  called  again 
that  night  and  there  was  no  pain. 

Patient  recovered  without  suffering  any  inconvenience,  her  bowels 


CLINICAL  SOCIETY.  128 

became  regular,  and  on  the  morning  of  the  ninth  day  afterward  she 
called  her  mother  in  alarm  saying  that  the  wound  must  have  started  to 
bleed.  The  mother  telephoned  for  me  and  I  went  out  and  found  that 
her  period  had  come  on  anB  she  had  begun  to  menstruate  freely  and 
without  a  trace  of  pain  for  the  first  time  in  her  life.  That  was  in 
March.  Since  then  she  has  menstruated  rcgularjy  and  has  never  had  a 
symptom  of  pain.     The  uterus  has  stayed  in  normal  position  and  she 

I  has  no  more  need  for  the  nostrums  she  formerly  imbibed. 

That  wedge-shaped  septum  formed  a  cup-pessary  which  tilted  the 
uterus  backw^ard,  and  when  the  organ  became  turgent  and  distended" 
with  blood  at  the  period,  occluded  the  os,  producing  the  pain  and  con- 

I  vulsions  until  the  flux  forced  itself  past  the  obstruction. 

i  The  girl  is  strong  and  well  and  is  not  so  much  afraid  of  doctors ; 

the  mother  is  pleased,  and  has  lost  a  very  large  part  of  her  confidence  in 
patent  medicines. 


CLINICAL  SOCIETY  OF  THE  NEW  YORK  POLYCLINIC. 


STATED  MEETING,  FEBRUARY  5,  1906. 

The  President,  JOHN  J.  MacPHEE.  M.  D.,  in  the  Chair. 
Reported  by  FREDERICK  C.  KELLER,  M.  D.,  Secretary. 

READING  OF  PAPERS. 
ACUTE  PELVIC  INFECTIONS, 


I  Doctor  Joseph  C.  Taylor  read  a  paper  on  the  above  subject.     He 

said,  in  part :  It  is  but  a  few  years  since  a  woman's  tubes  and  ovaries 
were  sacrificed  by  an  operator  lest  a  future  laparotomy  should  be 
required.  Actuated  by  a  sense  of  thoroughness,  he  deprived  women 
of  the  function  of  menstruation,  which  is  interwoven  with  their  mental 
as  well  as  physical  life.  It  is  better  to  conserve  these  organs,  even  if 
elaborate  and  hazardous  procedures  must  be  adopted  to  accomplish  this 
end  as  well  as  to  cure  the  patient.  He  did  not  advocate,  however,  the 
carrying  of  conservatism  in  connection  with  special  organs  so  far  as 
to  endanger  the  constitutional  condition  of  women.  There  is  a  broader 
conservatism,  which  seeks  to  restore  the  general  health  of  the  patient, 
even  if  special  organs  must  be  sacrificed  to  attain  such  an  end.  To 
this  end  he  made  an  appeal  for  early  surgical  interference  in  acute 
diseases  of  the  female  organs.  Conservative  operations  sometimes 
may  fail ;  but  even  if  they  do,  radical  procedures  must  be  adopted  later 
without  added  risk  to  the  patient.  On  the  other  hand,  it  is  impossible 
to  restore  organs  removed  by  radical  work. 

For  many  years  it  has  been  customary  in  most  large  hospitals  to 
treat  patients  suflfering  from  extension  of  gonorrheal  inflammation  to 
the  tubes  by  hot  antiseptic  douches  or  perhaps  by  tampons  and  an  ice- 


124  ORIGINAL  ARTICLES. 

bag  externally  over  the  lower  abdominal  region.  When  the  acuteness 
of  the  attack  had  somewhat  subsided  the  tubes  as  well  as  the  ovaries 
were  frequently  swollen  and  engorged  to  such  an  extent  as  to  be  desig- 
nated as  tumors  and  removal  was  advised ;  whereas,  without  apparent 
mutilation,  the  inflammation  might  have  been  checked  in  the  beginning 
and  the  woman  allowed  to  keep  her  organs,  though  somewhat  damaged. 
The  conservative  work  to  be  attempted  is  mainly  that  of  evacuating 
the  free  pus  in  the  culdesac  when  the  operator  is  convinced  by  the 
bulging  of  the  wall  of  the  posterior  fornix  that  purulent  exudate  is 
present  in  abundance.  The  gonococci,  in  an  active  state,  after  they 
have  gained  entrance  into  the  uterine  cavity,  cause  a  destruction  of 
the  superficial  cells,  work  their  way  into  the  deeper  layers,  and  are  the 
cause  of  an  immense  amount  of  purulent  exudate,  destruction  and 
infiltration  of  the  outer  layers  and  edema  of  the  deeper  structures. 
Unfortunately,  after  gonorrhea  has  once  become  well  established  within 
the  uterus,  it  invades  by  continuity  of  tissue  the  Fallopian  tubes.  The 
inner  surface  of  the  uterus  may  become  such  an  active  seat  of  inflam; 
mation  in  its  deeper  layers  that  the  walls  of  the  smaller  vessels  become 
involved,  as  do  the  surrounding  lympathics,  and  the  normal  structure 
is  almost  entirely  destroyed.  The  walls  of  the  uterine  cavity  thus 
become  suppurating  surfaces,  which  later  become  sclerotic,  and  this  is 
followed  by  a  shrinking  of  the  organ.  This  is  frequently  the  case  in 
mixed  infections. 

If  the  tubes  are  opened  and  drained  during  the  onset  of  the  disease, 
the  woman  may  retain  her  organs,  though  somewhat  damaged.  The 
operation  is  very  simple,  but  it  necessitates  a  thorough  knowledge  of 
female  pelvic  anatomy  and  careful  manipulation  of  special  instruments. 
An  incision  is  made  on  the  posterior  surface  of  the  cervix  at  the  junc- 
ture of  the  vaginal  mucous  membrane  with  the  cervical,  care  being 
taken  to  keep  close  to  the  cervix.  A  ^air  of  blunt-pointed  scissors, 
curved  on  the  flat,  seems  best  adapted  for  this  purpose.  When  the 
incision  is  made  in  the  curve  of  the  fornix,  a  painful  scar  is  apt  to 
result,  the  nearer  the  rectum  is  approached  the  greater  being  the  sensory 
nerve  supply.  After  incising  the  mucous  membrane  and  retracting  the 
divided  edges,  a  small  amount  of  loose  alveolar  tissue  is  encountered 
(most  marked  in  women  after  the  menopause).  After  incising  this  the 
peritoneum  is  easily  divided  or  punctured.  With  the  forefingers  the 
opening  can  be  enlarged.  The  uterosacral  ligaments  being  pushed 
outward  by  the  palmar  surfaces  of  the  fingers  and  the  intestines  carried 
out  of  the  way  by  means  of  the  Trendelenberg  position  and  held  there 
by  pads,  the  tubes  are  easily  brought  into  view  by  means  of  the  proper 
instruments  for  retraction.  If  this  procedure  is  adopted  in  the  very 
early  stages,  as  it  should  be,  the  tube  will  be  found  reddened,  swollen, 
and  with  a  tendency  to  sink  into  the  culdesac.  It  should  be  grasped 
with  a  pair  of  blunt  forceps,  such  as  those  of  the  modified  Hunter  type, 
on  the  dorsal  surface,  and  pulled  into  the  opening.  It  should  be  remem- 
bered that  the  tube,  like  the  ovary,  except  at  its  uterine  extremity,  is 


CLINICAL  SOCIETY.  125 

fed  by  small  ascending  branches  from  the  ovarian  artery,  which  enter 
the  structure  from  the  lower  surface;  consequently,  when  an  incision 
is  made  it  should  be  on  the  opposite  side.  Care  should  be  taken  to 
keep  the  intestines  out  of  the  way  by  means  of  pads,  the  tubes  being 
incised  along  the  outer  two-thirds  of  the  upper  border.  The  contents 
should  then  be  evacuated  and  the  entire  surface  thoroughly  swabbed 
with  five-per-cent  iodoform  gauze.  At  first  there  will  be  considerable 
oozing  of  blood,  which  gradually  subsides,  no  main  vessel  having  been 
cut.  A  small  strip  of  iodoform  gauze  should  then  be  placed  over  the 
raw  surface,  an  end  protruding  into  the  vagina.  The  first  eflFect  of 
this  treatment  is  to  reduce  the  interstitial  cellular  infiltration,  as  it  is 
a  well-known  fact  that  the  gonococcus  does  not  thrive  well  on  exposed 
surfaces,  its  natural  abode  being  in  the  deep  recesses  of  compound 
racemose  glands.  The  gauze  may  be  removed  from  the  culdesac  in 
from  five  to  six  days.  This  may  be  done  with  safety  after  such  a 
period,  as  the  life  of  the  gonococcus  at  best  is  very  short,  except  in 
racemose  glands  and  closed  sacs. 

REPORTS  OF* CASES. 

FRACTURE  OF  THE  ULNA  DURING  MASSAGE  FOLLOWING  OPERATION 
FOR  COLLESr  FRACTURE. 

Doctor  Frederick  C.  Keller  :  I  wish  to  show  this  patient.  After 
the  removal  of  the  splint  her  arm  was  being  massaged  when  the  ulna 
snapped  at  a  point  several  inches  above  the  original  site  of  fracture. 
This  occurred  six  or  eight  weeks  after  the  operation,  and  could  be 
attributed  only  to  some  inherent  disease  of  the  bone. 

DISCUSSION. 

Doctor  Joseph  C.  Robertson  :  I  have  put  up  from  two  hundred 
to  three  hundred  cases  of  Colles'  fractures  during  the  past  eight  years, 
and  until  two  years  ago  have  applied  a  posterior  splint,  the  arm  being 
semiflexed  in  a  stiflf  position.  This  gave  far  from  perfect  results  in 
eight  out  of  ten  cases.  A  careful  study  of  these  cases  has  convinced 
me  that  the  best  results  are  obtained  by  applying  a  posterior  splint 
from  the  hand  to  the  elbow,  keeping  the  arm  perfectly  straight,  and 
putting  a  pad  of  cotton  under  the  wrist.  As  a  result  there  is  no  sharp 
protrusion  of  the  ulna  at  the  elbow,  as  often  occurs  when  the  hand  is 
put  up  anteflexed. 

Doctor  John  A.  Bodine:  Something  was  wrong  with  the  com- 
position of  the  bones  of  this  patient,  as  ulnas  do  not  snap  from  massage. 
The  bones  were  probably  chalky.  As  to  Doctor  Robertson's  experience 
with  Colles'  fractures,  I  think  that  each  surgeon  favors  the  line  of 
treatment  with  which  he,  personally,  has  obtained  the  best  results.  I 
think  a  posterior  splint  more  practical,  for  the  reason  that  the  posterior 
surface  of  the  arm  is  a  straight  surface,  and  has  no  cutaneous  nerves 
and  no  return  blood  supply.  If  a  rigid  anterior  splint  is  applied  to  the 
front  of  the  arm,  edema  is  caused  by  obstruction  of  the  circulation. 


126  ORIGINAL  ARTICLES 

INTUSSUSCEPTION. 

Doctor  Alexander  Lyle:  I  desire  to  report  a  case  of  intussus- 
ception occurring  in  a  child  seven  and  one-half  months  old.  The 
patient,  well-nourished,  healthy,  active  and  breast-fed,  had  enjoyed 
perfect  health,  with  the  exception  of  constipation,  until  the  evening  of 
December  i8,  1905,  when  he  was  suddenly  seized  with  severe  abdominal 
pain,  as  evidenced  by  crying  and  flexion  of  the  thighs  upon  the  abdomen. 
He  was  given  a  hot  mustard  footbath,  and,  internally,  hot  water  with 
gin  and  paregoric.  His  bowels  had  moved  normally  on  the  preceding 
day,  but  not  on  the  day  of  the  attack.  At  i  a.  m.  the  child  passed  about 
half  an  ounce  of  bloody  mucus  but  no  fecal  matter.  Pain  was  severe 
and  recurrent  in  character  and  at  6  a.  m.  on  the  19th  a  physician  was 
summoned.  He  ordered  half  an  ounce  of  castor  oil.  This  failed  to 
produce  an  evacuation  of  the  bowels.  On  the  evening  of  the  19th  he 
ordered  an  enema  (rectal)  of  glycerine  and  hot  water.  During  the 
night  the  mother  noticed  a  sudden  change  in  the  child's  condition  and 
thought  it  to  be  dying.  She  could  not  reach  the  physician,  and  in  the 
morning  I  was  summoned.  On  reaching  the  house  I  found  that  the 
physician  had  arrived  and  had  given  an  enema  of  an  ounce  of  castor 
oil  and  one  pint  of  warm  water,  the  water  returning  with  bloody  mucus. 

Hasty  examination  showed  a  state  of  collapse,  a  weak  pulse  that 
could  not  be  counted,  a  tense,  rigid  abdomen,  and  a  rectal  temperature 
of  103°  Fahienheit.  A  diagnosis  of  intussusception  was  made  and 
immediate  operation  advised  as  offering  the  only  hope  (and  that  a  poor 
one.) 

'  The  child  was  immediately  brought  to  the  Polyclinic  Hospital  and 
operated  upon.  No  tumor  could  be  mapped  out,  even  after  he  had 
been  anesthetized.  An  incision  was  made  in  the  right  rectus  muscle, 
just  below  the  umbilicus,  the  abdominal  contents  examined  and'  intus- 
susception located  in  the  ileocecal  region.  A  firm,  dense  band  of 
adhesion  anchored  this  portion  of  the  intestine,  necessitating  a  con- 
siderable amount  of  work  before  it  could  be  brought  into  the  wound. 
This  was  finally  accomplished  and  the  intussusception  reduced.  The 
gut  was  not  gangrenous  and  therefore  was  returned  to  the  abdominal 
cavity.  A  loop  of  small  intestine  w^as  picked  up  and  two  drams  of 
saturated  solution  of  magnesiurn  sulphate  was  thrown  into  it  by  means 
of  a  syringe,  the  needle  of  which  was  carried  obliquely  into  the  lumen, 
the  object  being  to  evacuate  the  bowels  as  soon  as  possible.  The 
abdominal  wound  was  then  closed. 

Following  the  operation  the  child's  temperature  rose  to  103.5° 
Fahrenheit,  and  remained  so  until  i  a.  m.  of  the  next  day,  when  it 
dropped  gradually  to  99.5°  Fahrenheit,  and  did  not  rise  above  100.8° 
Fahrenheit  at  any  time  afterward.  The  pulse  could  not  be  counted 
until  the  temperature  had  fallen  to  101.8°  Fahrenheit,  when  it  was  160, 
later  falling  to  118  or  120.  The  bowels  moved  five  times  during  the 
first  twenty-four  hours  after  the  operation. 


CLINICAL  SOCIETY.  127 

I  would  emphasize  the  point  that  valuable  time  must  not  be  lost  by 
useless,  or,  more  properly  speaking,  positively  injurious  and  dangerous 
medication.  The  sudden  abdominal  pain,  followed  by  a  discharge  of 
bloody  mucus  from  the  rectum,  the  recurrent  attacks  of  pain  and 
absence  of  fecal  exacuations  indicate  immediate  operation.  Gangrene 
or  extensive  adhesions,  or  both,  are  produced  by  delay,  and  an  intes- 
tinal resection  and  circular  enterorrhaphy  will  be  necessary.  An  early 
operation,  on  the  contrary,  enables  the  surgeon  to  early  effect  reduction. 

DISCUSSION. 

Doctor  Bodine  :  One  point  should  be  emphasized  in  the  diagnosis 
of  an  inflammatory  abdominal  condition  in  a  child,  and  that  is  the 
expression  of  the  face,  which  is  always  typical.  Another  aid  is  the 
abdominal  pain.  I  think  it  would  have  been  impossible  to  have  made 
a  differential  diagnosis  between  this  condition  and  appendicitis  if  it 
had  not  been  for  the  presence  of  the  bloody  mucus. 

Doctor  Maurice  Packard  :  In  cases  of  abdominal  lesions  in  chil- 
dren up  to  three  years  of  age,  the  differential  diagnosis  between  intus- 
susception and  strangulated  hernia  usually  has  to  be  made.  The  only 
point  in  diagnosis  especially  pointing  to  intussusception  is  the  bloody 
mucus.  A  body  temperature  of  103°  Fahrenheit,  and  a  rapid  pulse 
are  also  significant,  as  the  statement  is  made  in  many  text-books  that, 
except  in  appendicitis  and  general  peritonitis,  the  temperature  and  pulse 
are  normal  and  the  abdomen  relaxed.  It  has  been  my  experience  that 
in  intussusception  children  always  have  a  high  temperature  and  have 
a  pulse  so  rapid  that  it  is  almost  impossible  to  count  it.  In  cases  of 
intestinal  obstruction  the  absence  of  stools  and  gas  assists  one  in  making 
a  differential  diagnosis,  as  in  intussusception  only  mucous  and  blood 
pass  from  the  bowels. 

LARGE  OVAR/AX  CyS7\ 

Doctor  Charles  G.  Child,  Jr.  :  I  removed  this  cyst  from  a  patient 
thirty-eight  years  of  age.  She  has  complained  of  pain  for  four  or  five 
years,  during  which  time  she  noticed  the  presence  of  a  tumor,  which 
grew  progressively  larger.  Examination  revealed  an  enlargement 
reaching  to  the  umbilicus.  It  was  impossible  to  palpate  the  appen- 
dages on  either  side,  and  it  was  also  impossible  to  determine  on  which 
side  the  tumor  originated.  On  account  of  the  pain  being  on  the  right 
side  it  was  concluded  that  the  tumor  was  of  the  right  ovary,  but  at 
the  time  of  operation  it  was  found  to  involve  the  ovary  on  the  left  side 
and  to  have  rotated  the  uterus.  It  firmly  compressed  the  appendages 
on  the  right  side,  which  accounted  for  the  pain  on  that  side.  A 
transverse  incision  showed  the  cyst  to  be  inherent  in  all  directions  to 
the  omentum  and  posterior  peritoneum.  A  portion  of  it  was  free  from 
adhesions,  and  at  this  point  the  fluid  contents  were  aspirated.     The 


128  ORIGINAL  ABSTRACTS. 

sac  was  then  pulled  out,  with  the  intestines  and  omentum,  and  the 
adhesions  separated.  The  sac  contained  a  dark,  water-like  fluid,  which 
is  rather  unusual,  the  contents  of  such  a  tumor  usually  being  of  a 
yellow  straw  color. 


ORIGINAL  ABSTRACTS. 


MEDICINE. 

By  GEORGE  DOCK,  A.  M.,  M.  D.,  D.  Sc,  Ann  Arbor,  Michigan. 

PKOriSSOK  OP  MWDICINB  IN  THE  UKIVBRSITT  OF  MICHIGAN. 

AND 

DAVID  MURRAY  COWIE,  M.  D.,  Ann  Arbor,  Michigan. 

FIRST  ASSISTANT  IN  MBDICINB  IN  THB  UNIVERSITY  OF  MICHIGAN. 


THE  RHYTHMIC  SOUNDS  OF  THE  ALIMENTARY  CANAL. 

In  a  decidedly  interesting  description  of  a  series  of  investigations  into 
the  causes  of  the  various  sounds  produced  in  the  gastroenteric  canal, 
Cannon  (Jama,  January  20,  1906)  concludes  that  stomach  sounds  are 
best  heard  over  the  pyloric  ring  at  the  tip  of  the  eighth  rib.  These 
sounds  are  explosive  in  their  character,  loud,  and  correspond  with  the 
rhythmical  contraction  of  the  pylorus,  they  occur  about  once  in  every 
twenty  seconds  and  are  distinguished  by  auscultation  with  a  stetho- 
scope. Small  intestine  sounds  can  be  differentiated  from  those  of  the 
stomach  and  large  intestine  sounds  by  auscultation  over  the  lower  por- 
tion of  the  abdomen.  These  sounds  are  best  heard  when  the  stomach  is 
empty,  in  the  early  morning,  and  particularly  over  the  lower  left 
quadrant;  the  object  of  this  position  is  to  get  as  far  away  from  the 
active  portion  of  the  colon  as  possible.  The  sounds  are  soft,  confused, 
rolling,  rising  and  falling  in  intensity,  not  rattling  and  explosive  like 
those  of  the  stomach.  They  continue  for  four  or  five  seconds,  disap- 
pear, and  return  again  at  intervals  of  seven  or  eight  seconds,  and  persist 
in  the  same  location  for  indefinite  periods  of  time. 

The  sounds  of  the  large  intestine  present  no  periodicity,  are  easily 
distinguished  from  the  other  sounds,  and  are  heard  over  any  portion  of 
the  active  colon,  the  ascending  and  transverse  portions.  The  sounds 
are  very  coarse  and  rumbling,  with  heavy  gushes  of  gas  from  one  seg- 
ment to  another.  The  intervals  are  longer,  from  fifteen  to  forty-five 
seconds. 

The  author  used,  as  a  method  of  eliminating  the  personal  equation, 
a  recording  telephonic  transmitter.  The  article  should  be  read  with 
care,  as  it  is  impossible  to  do  justice  to  it  in  a  brief  review.  The  sounds 
are  somewhat  dependent  upon  the  character  of  the  food  eaten,  that  is, 
certain  sounds  can  be  better  differentiated  if  certain  substances  are 
eaten.  d.  m.  c. 


TREATMENT  OF  FRACTURE.  129 


SURGERY. 


Bv  FRANK  BANGHART  WALKER,  Ph.  B.,  M.  D.,  Detroit.  Michigan. 
rmowwMom  op  svmGBitT  amd  opbrativb  surgbkt  in  the  dbtkoit  postgkaouatb  school  of  MBDiaMi; 

ADJUNCT  FKOPUaOK  OP  OPBBATIYB  SUKCBKT  IN  THB  DBTKOIT  COLLBGB  OP  MBOiaNB. 

AND 

CYRENUS  GARRITT  DARLING,  M.  D.,  Ann  Arbor,  Michigan. 

CLINICAL  PBOPBSaOK  OP  SUBOBBT  IN  THB  VNIYBBSITT  OP  MICHIGAN. 


THE  MODERN  TREATMENT  OF  FRACTURE. 

Carl  Beck,  M.  D.,  of  New  York  (Medical  Record,  Volumel.XIX, 
Number  XII).  It  is  quite  refreshing  to  read  an  article  with  the  above 
title,  in  which  the  writer  dares  to  advance  new  ideas  and  cut  away  from 
some  of  the  traditions  which  have  long  interfered  with  the  scientific 
treatment  of  fractures. 

The  Roentgen  ray  has  not  only  become  a  valuable  aid  in  diagnosis, 
but  compels  much  better  resuhs  in  treatment.  Injuries  that  were  for- 
merly treated  as  dislocations,  sprains,  contusions  or  distortions  are  now 
known  to  be  fractures,  a  glance  through  the  fluoroscope  revealing  the 
true  condition. 

Fractures  without  displacement,  entering  an  articulation,  may  have 
considerable  effusion.  Without  knowing  the  condition  the  surgeon 
would  be  strongly  tempted  to  manipulate.  A  skiagraph  would  at  once 
show  the  condition  and  suggest  the  line  of  treatment.  The  writer 
prefers  a  plaster-of-Paris  dressing  because  it  adapts  itself  to  any  part 
of  the  body  and  offers  no  obstacle  to  the  Roentgen  rays. 

The  rules,  that  fragments  must  be  reduced,  and  that,  after  proper 
position  has  been  attained  fixation  is  in  order,  while  simple,  are  fre- 
quently violated. 

The  dogma  that  the  soft  tissues  are  the  most  important  part  of  the 
treatment  of  fractures,  is  dangerous.  Repair  must  take  place  in  the 
bone,  while  the  soft  parts  may  be  injured  by  imperfect  reduction.  With 
perfect  reduction  joints  and  tendon-sheaths  are  at  once  set  free  and 
remain  so,  unless  immobilized  for  a  long  time. 

A  fracture  is  a  wound  in  which  union  by  first  intention  is  desired ; 
accurate  coaptation  of  parts  is  therefore  necessary.  What  was  for- 
merly regarded  by  many  as  bone  callus  was  nothing  but  a  displaced 
borie  fragment.  The  only  way  to  insure  the  exact  reposition  is  by 
using  the  Roentgen  ray.  The  practitioner  must  resort  to  this  not  only 
for  the  good  of  his  patient  but  for  his  own  protection. 

In  old  displacements  of  not  more  than  two  weeks  standing  refrac- 
ture  may  be  successfully  performed  under  anesthesia.  Old  fractures 
are  to  be  opened  and  refractured  with  a  thin  broad  chisel;  in  such 
cases  when  there  is  great  tendency  to  displacement  suturing  with  bronze 
wire  is  indicated.  Periosteal  shreds  may  become  ossified  and  lead  to 
deformity.  When  the  bone  is  treated  by  open  operation  these  should 
be  carefully  removed. 

The  patella  offers  a  good  example  for  technique  of  operation.     It 


130  ORIGINAL  ABSTRACTS. 

has  little  tendency  to  osseous  regeneration.  Effusion  following  frac- 
ture tends  to  keep  the  fragments  apart.  Contraction  of  the  muscles 
tends  to  keep  them  separated,  and  soft  tissues  interpose  to  fill  the  gap. 
The  Roentgen  ray  shows  that  not  in  a  single  instance  is  reduction 
perfect  even  under  anesthesia.  The  only  rational  remedy  is  to  open 
the  joint,  remove  the  intervening  structures,  and  accurately  replace  the 
suture  with  catgut  or  bronze  wire,  according  to  conditions. 

A  number  of  histories  are  given  to  illustrate  the  points  taken.  The 
views  which  he  holds  are  summarized  as  follows: 

( 1 )  The  Roentgen  method,  in  combination  with  the  usual  methods 
of  examination,  determines  the  character  of  the  suspected  bone  injury. 

(2)  If  there  be  no  bone  injury,  the  proper  treatment  consists  in 
massage,  followed  by  immobilization,  a  movable  splint  being  prefer- 
able for  the  latter  purpose. 

(3)  If  there  is  a  fissure  or  fracture,  followed  by  no  displacement, 
manipulations  of  the  injured  area  must  be  avoided  and  immobilization 
m  the  most  comfortable  position  applied.  As  a  rule,  plaster-of-Paris 
dressing  answers  the  purpose  best.  After  two  or  three  weeks  it  must 
be  removed  and  massage  begun.  In  about  two  weeks  a  splint  of 
plaster-of-Paris  is  applied,  which  the  patient  can  take  oflf  and  reapply. 

(4)  If  there  is  any  displacement,  reduction  must  be  applied  at  once. 
This  can  be  done  under  the  control  of  the  fluoroscope  on  a  translucent 
table,  a  plaster-of-Paris  dressing  being  applied  after  reposition  is  per- 
fect. This  is  a  simple,  short  and  cheap  method.  A  more  tedious,  but 
a  safer  way  is  to  reduce  the  displacement  under  the  guidance  of  a 
skiagraph  taken  before.  This  will  indicate  in  which  direction  the 
efforts  at  reduction  must  be  made,  and  how  far.  After  a  plaster-01- 
Paris  dressing,  padded  with  cotton  layers  at  its  ends  only,  is  applied, 
the  skiagraph  is  taken  through  it  in  order  to  ascertain  whether  reposi- 
tion was  complete.  If  it  does  not  seem  to  be,  the  dressing  must  be 
removed  and  another  attempt  at  reposition  made.  If  the  process  of 
reduction  meets  with  difficulties,  an  occurrence  which  can,  as  a  rule, 
be  anticipated  from  the  nature  of  the  skiagraph,  anesthesia  should  be 
employed. 

(5)  In  those  cases,  in  which,  on  account  of  entanglement  of  the 
fragments,  extensive  splinter  formation,  or  similar  complications,  repo- 
sition'even  under  anesthesia  cannot  be  accomplished,  the  fragments 
must  be  exposed  by  the  scalpel  and  brought  into  apposition.  If  there 
be  no  tendency  to  displacement,  a  plaster-of-Paris  dressing  will  insure 
immobilization.  But  if  the  fragments  slip  out  easily,  it  is  safer  to 
unite  them  with  catgut,  provided  there  is  enough  periosteum  to  be 
utilized  for  that  purpose.  Otherwise  it  is  best — especially  if  large 
bones  come  into  consideration — to  keep  them  together  with  a  bronze 
wire  suture.  The  sooner  this  is  done  the  better  it  will  be,  because  the 
smaller  are  the  changes  taking  place  in  the  soft  tissues.       c.  g.  d. 


BACTERIOLOGY  OF  PERITONITIS.  131 


GYNECOLOGY. 


By  REUBEN  PETERSON,  A.  B.,  M.  D.,  Ann  Arbor,  Michigan. 

ntOilllllK  or  GTMBCOLOGT  AND  OBSTBTKICS  IN  THE  UNIYBKSITY  OP  MICHIGAN. 

AND 

CHRISTOPHER  GREGG  PARNALL,  A.  B..  M.  D..  Ann  Arbor,  Michigan. 

FIKST  ASSISTANT  IN  GTNKOLOOT  AND  OBBTBTRICS  IN  THE  UNIYnSfTT  OP  MICIIIOAN. 


RECENT  RESEARCHES  INTO  THE  BACTERIOLOGY  OF 
PERITONITIS  IN  RELATION  TO  PELVIC  SURGERY. 

Sargent  {Journal  of  Obstetrics  <md  Gynecology  of  the  British 
Empire,  Volume  XI,  Number  III)  devotes  an  extended  study  to  the 
bacteriology  of  peritonitis  in  relation  to  pelvic  surgery.  Peritonitis  is 
to  be  regarded  as  a  secondary  or  terminal  process  in  the  course  of  other 
diseases,  many  of  which  may,  in  themselves,  be  without  dangerously 
serious  import.  The  avenues  through  which  infection  may  enter  are: 
(i)  Accidental  or  operation  wounds;  (2)  Rupture  or  perforation  of 
a  hollow  viscus',  a  cyst,  or  an  abscess;  (3)  Passage  of  germs  from  an 
infected,  but  not  perforated,  hollow  viscus,  cyst  or  abscess ;  (4)  Indirect 
infection  of  blood  extravasated  into  the  peritoneal  cavity  in  such  quan- 
tities as  to  be  not  readily  absorbed;  (5)  Infection  by  way  of  the  blood- 
stream. 

The  writer,  after  many  observations  in  cases  of  peritonitis  in  gen- 
eral, comes  to  the  conclusion  that  certain  types  of  the  disease  may  be 
recognized  and  differentiated  according  to  the  kind  of  infecting  agent. 
The  organisms  found  were,  in  order  of  frequency,  the  staphylococcus 
albus,  the  colon  bacillus,  the  streptococcus,  bacillus  pyocyaneus,  pneu- 
mococcus,  gonococcus,  and  staphylococcus  aureus.  Although  the 
staphylococcus  albus  was  the  organism  most  frequently  found  it  is 
thought  to  exercise  a  beneficial  influence  when  associated  with  other 
germs  as  it  causes  a  marked  phagocytosis.  The  colon  bacillus  is  the 
most  important  causative  factor  in  peritonitis,  the  type  of  the  inflamma- 
tion varying  with  the  virulence  of  the  infection.  The  streptococcus 
was  rarely  found,  but  when  present  gave  rise  to  a  rapidly  fatal  fonn  of 
the  disease.  Of  rare  occurrence  as  causes  of  peritonitis  are  the  bacillus 
pyocyaneug,  the  pneumococcus,  and  the  gonococcus. 

In  considering  peritonitis  arising  from  diseases  of  the  female  pelvic 
organs,  the  author  states  that  the  relative  frequency  is  changed.  The 
less  virulent  infecting  agents  are  more  common  in  inflammation  con- 
fined to  the  pelvic  peritoneum.  Peritonitis  of  pelvic  origin  is  consid- 
ered under  five  divisions:  (i)  Extrauterine  gestation;  (2)  Salpingitis: 
(3)  Inflamed  ovarian  cysts;  (4)  Infections  connected  with  pregnancy; 
(5)  Accidental  infections. 

(i)  Extrauterine  Gestation, — In  seventeen  cases  examined,  a 
staphylococcus  albus  of  low  virulence  was  isolated  in  each  case.     The 


132  ORIGINAL  ABSTRACTS. 

infection  starts  in  blood  clots  resulting  from  rupture  of  the  sac.  The 
same  organism  was  present  in  cases  of  intraabdominal  hemorrhage 
following  rupture  of  the  liver  and  spleen. 

(2)  Salpingitis, — Tubal  inflammation  is  the  most  common  cause  of 
peritonitis  met  with  in  gynecological  surgery.  The  process  is  usually 
of  a  comparatively  mild  type,  occurring  either  by  direct  extension  or 
through  rupture.  The  pus  sac,  in  case  of  salpingitis,  generally  speak- 
ing, contains  the  gonococcus  or  is  sterile.  Cultivation  of  the  gonococcus 
is  so  difficult  that  this  fact  may  account  for  the  repeated  failure  of 
many  observers  to  recognize  the  organism  as  a  cause  of  peritonitis. 
Since  the  inflammatory  process  in  cases  of  gonorrheal  peritonitis  is  of 
such  a  mild  character,  it  is  rarely  necessary  to  employ  drainage. 

(3)  Inflamed  Ovarian  Cysts, — Only  three  cases  were  investigated 
bacteriologically.  Two  of  the  cases  showed  a  colon  bacillus  infection 
of  the  cyst  contents,  and  the  third  a  streptococcus  infection  of  the  cyst 
with  staphylococcus  albus  present  in  the  peritoneal  exudate. 

(4)  'Infections  connected  ivith  Pregnancy,^— No  examples  of  these 
infections  occurred.  From  a  study  of  the  literature,  the  peritonitis 
following  puerperal  sepsis  is  often  of  streptococcus  origin  and  is  gen- 
erally fatal. 

(5)  Accidental  Infections. — Any  of  the  organisms  mentioned  may 
be  the  cause  of  postoperative  peritonitis,  the  kind  of  infection  depending 
on  the  location  of  the  field  of  operation.  One  case  of  fatal  postoperative 
peritonitis  due  to  the  bacillus  pyocyaneus  is  mentioned.  There  was 
also  one  instance  of  pneumococcus  peritonitis. 

From  the  bacteriological  investigations,  the  author  draws  his  con- 
clusions, regarding  treatment,  under  the  following  divisions: 

( 1 )  Operative  Treatment. — Since  the  recovery  of  a  patient  suffer- 
ing from  peritonitis  depends  largely  on  the  leucoc3rtes  of  the  exudate 
acting  as  phagocytes,  the  surgeon  should  limit  his  operative  inter- 
vention to  thorough  drainage  and  local  cleansing.  No  unwarranted 
attempts  should  be  made  to  remove  diseased  structures,  and  the 
leucocyte  barrier  must  not  be  washed  away  by  copious  irrigation.  In 
cases  of  intraabdominal  or  intrapelvic  hemorrhage,  the  blood  may  be 
removed  by  irrigations  of  salt  solution  as  the  infection  at  first  is  mild, 
and  there  is  always  danger  of  after-infection  of  blood  clots  by  virulent 
organisms. 

(2)  Drug  Treatment. — The  writer  merely  considers  the  inadvis- 
ability  of  using  opium.  This  drug  masks  the  symptoms,  may  be  a 
contributory  agent  in  causing  intestinal  paralysis,  and,  according  to 
Dudgeon  and  Ross,  inhibits  leucocytosis. 

(3)  Specific  Serum  Treatment. — In  all  cases  of  peritonitis  the 
writer  urges  an  attempt  to  early  recognize  the  infecting  agent  and 
then  to  employ  a  corresponding  multivalent  serum.  Results,  so  far, 
in  Sargent's  experience  with  serum  therapy,  have  been  "sufficiently 
suggestive  to  w^arrant  an  extensive  trial"  of  the  method.       c.  G.  p. 


EXAMINATION  OF  RESPIRATORY   PASSAGES.  133 

PEDIATRICS. 

Bv  ARTHUR  DAVID  HOLMES.  M.  D..C.  M..  Detroit,  Michigan. 


THE    FREQUENCY,    PROGNOSIS    AND    TREATMENT    OF 
LOBAR  PNEUMONIA  IN  INFANTS  AND  CHILDREN. 

KoPLiK  (Boston  Medical  and  Surgical  Journal,  Number  I,  1905) 
says  double  pneumonia  in  children  is  less  frequent,  but  involement  of 
the  upper  lobes  is  more  frequent  as  compared  with  adults.  The  prog- 
nosis depends  upon  the  age,  severity,  kind  of  infection  and  complica- 
tions, but  as  a  rule  cases  below  the  tenth  year  offer  the  best  prognosis. 
The  author's  greatest  mortality  occurred  below  the  age  of  two  and  a 
half  years,  and  was  greater  in  the  winter  months.  A  marked  absence 
of  leucocytosis  foreshadows  an  unfavorable  termination.  He  says  a 
complicating  otitis,  pleurisy  or  empyema  do  not  materially  influence 
the  prognosis,  if  they  are  recognized  early,  and  treated  properly.  Hy- 
drotherapy is  our  sheet-anchor — sponging  and  cold  compresses — in 
controlling  the  temperature  if  it  is  doing  harm.  If  the  child  does  not 
react  well  with  cold,  substitute  tepid  sponging.  The  author  has  not 
seen  much  benefit  from  the  use  of  oxygen,  but  advises  thorough 
ventilation,  the  room  being  kept  at  a  temperature  of  68°  Fahrenheit. 
Support  the  heart  and  administer  strychnin.  For  the  cough  and  pain 
give  codeia  to  the  older,  and  paregoric  to  the  younger  children.  For 
collapse,  place  heat  to  the  heart  and  extremities  and  administer  camphor 
and  nitroglycerine. 

LARYNGOLOGY. 

By  WILLIS  SIDNEY  ANDERSON.  M.  D..  Detroit,  Michigan. 

ASSISTANT  TO  THE  CHAIR  OF  LARYNGOLOGY  IN  THE  DETROIT  COLLEGE  OP  MEDICINE. 


THE  CLINICAL  VALUE  OF  THE  DIRECT  EXAMINATION 

OF  THE  RESPIRATORY  AND  SUPERIOR 

DIGESTIVE  PASSAGES. 

Carl  von  Eicken  (Archiv,  fUr  Laryngology,  XV,  Number  III) 
gives  a  general  resume  of  the  value  of  autoscopic  examinations  as 
developed  by  Kirstein.  He  speaks  first  of  its  value  in  the  examination 
of  children,  where  it  is  so  difficult  to  use  a  laryngoscope.  It  enables 
the  examiner  to  inspect  the  larynx  by  direct  vision.  Foreign  bodies 
in  the  larynx,  or  trachea,  can  be  located  and  removed  with  great  pre- 
cision. In  stenosis  and  displacements  of  the  larynx,  retropharyngeal 
tumors,  projections  of  the  posterior  wall  of  the  pharynx,  the  direct 
method  offers  many  advantages.  The  author  speaks  of  this  method 
in  goitre,  especially  in  diagnosing  the  endotracheal  variety,  or  in  malig- 
nant disease  of  the  gland  where  the  trachea  is  involved.  Certain 
aneurysms  of  the  ascending  arch  of  the  aorta,  which  are  to  be  differ- 
entiated from  intrathoracic  goitre,  carcinoma  of  the  esophagus  and 


134  ORIGINAL  ABSTRACTS. 

Other  mediastinal  affections  can  be  accurately  diagnosed  by  direct 
tracheoscopic  examinations.  The  bronchi  and  the  esophagus,  as  well 
as  the  trachea,  can  be  examined  by  this  method,  and  the  surgery  of 
these  passages  can  be  made  more  exact. 


GANGRENE  OF  THE  TONSIL. 
Charles  W.  Richardson  {American  Journal  of  the  Medical 
Sciences,  October,  1905)  reports  two  fatal  cases  in  his  own  practice 
and  abstracts  of  three  cases  found  reported  in  literature.  The  condition 
is  rare,  the  laboratory  findings  are  of  little  help  to  diagnosis,  and  a  fatal 
termination  seems  to  be  the  rule.  One  of  the  reported  cases  showed 
upon  examination  a  grayish,  brownish,  putty-like  slough  on  the  right 
tonsil,  anterior  and  posterior  pillars  and  as  far  down  the  pharynx  as 
one  could  see.  The  odor  of  the  breath  is  always  offensive,  the  tempera- 
ture is  indicative  of  sepsis,  and  the  prostration" is  marked.  The  source 
of  infection  in  the  cases  reported  could  not  be  traced.  One  of  the 
author's  cases  was  of  the  moist,  the  other  of  the  dry,  type  of  gangrene. 

PROCTOLOGY. 

Bv  LOUIS  JACOB  HIRSCHMAN,  M.  D.,  Detroit,  Michigan. 

CUmCAL  PR0FBS80R  OF  PROCTOLOGY   IN  THE  DBTROIT  COLLBCB  OF  MBDICINB. 

THE  TREATMENT  OF  HEMORRHOIDS. 

Charles  B.  Kelsey,  in  The  Therapeutic  Gazette,  Volume  XXH, 
Number  HI,  states  that  years  ago  he  abandoned  the  use  of  the  ligature 
for  the  clamp  and  cautery.  The  clamp  and  cautery  in  his  hands  has 
always  been  satisfactory,  where  the  patients  were  willing  to  submit  to 
operation  under  general  anesthesia.  His  reasons  for  preferring  the 
clamp  to  the  ligature  were  at  first  that  it  caused  less  pain  and  gave 
quicker  convalescence;  now  he  is  convinced  that  the  pain  caused  by 
either  operation  depends  far  more  upon  the  individual  technique  and 
skill  of  the  operator  than  upon  the  method  of  closing  the  operation. 
He  wishes  to  emphasize  that  the  clamp  and  cautery  is  the  last  step  of 
the  operation  for  piles  and  not  the  operation  itself.  The  operation  con- 
sists of  dissecting  the  pile  from  its  attachments  as  far  up  toward  its  base 
as  is  consistent  with  safety,  and  the  dissected  mass  in  the  grasp  of  the 
forceps  is  either  cut  off  and  tied,  or  clamped  and  cauterized.  Kelsey 
usually  does  the  latter,  but  on  some  occasions  still  uses  the  ligature  as 
taught  by  Allingham. 

Kelsey  states  that  either  operation  may  be  done  in  suitable  cases 
under  local  anesthesia.  Where  the  sphincters  cannot  be  fully  stretched, 
general  anesthesia  is  demanded.  He  absolutely  opposes  the  White- 
head and  the  "American"  operation,  on  account  of  the  many  cases  of 
stricture  and  ulceration  following  them,  and  states  that  he  abandoned 
the  injection  treatment  years  ago,  on  account  of  its  many  septic 
sequences,  and  inherent  dangers.  After  a  systematic  search  for  some 
method  which  would  accomplish  a  cure  without  general  anesthesia  or 


HEREDITARY   SYPHILIS.  136 

confinement  to  bed,  Kelsey  adopted  the  method  of  punctate  cauteriza- 
tion by  means  of  the  galvanocautery.  His  technique  is,  briefly:  Ten 
or  fifteen  minims  of  a  weak  eucain  solution  are  injected  into  the  most 
prominent  part  of  the  tumor  through  the  Kelsey  speculum  until  disten- 
sion is  produced.  After  waiting  for  a  few  minutes  to  allow  the  anes- 
thetic to  take  eflFect,  a  fine  platinum  cautery  needle,  heated  to  redness, 
is  plunged  into  the  substance  of  the  tumor.  Not  over  two  applications 
are  made  at  a  sitting,  and  these  not  oftener  than  twice  a  week.  If 
much  pain  and  soreness  results  it  is  well  to  wait  a  week  for  healing. 
This  treatment  takes  several  wrecks  to  effect  a  cure,  and  the  patient  can 
attend  to  his  usual  vocation.  Kelsey  reports  cures  of  as  long  as  ten 
years  standing  in  prolapsing  and  bleeding  hemorrhoids,  and  has  never 
had  an  unpleasant  complication  or  sequela. 


DERMATOLOGY. 

By  WILLIAM  FLEMING  BREAKEY.  M.  D..  Ann  Arbor,  Michigan. 

CUNICAL  PROPBSaOlt  OP  DSKMATOLOGT  AND  STFHILOLOGT  IN  THE  UNXVKMITT  OV   MICHIGAN. 

AND 

JAMES  FLEMING  BREAKEY,  M.  D.,  Ann  Arbor,  Michigan. 

ASSISTANT  IN  DERMATOLOGY  IN  THE  UNIVERSITY  OP  MICHIGAN. 


INFLUENCE  OF  PATERNAL  INHERITANCE  ON  HEREDI- 
TARY SYPHILIS. 

August  Ravogli  (American  Journal  of  Dermatology,  October, 
1905)  discusses  inherent  syphilis,  paternal,  maternal  and  both. 

In  many  cases  Colles'  law  is  but  a  proof  of  latent  infection,  and  a 
woman  married  to  a  syphilitic  man,  may,  during  pregnancy,  be  infected 
by  her  ow^n  syphilitic  child.  This  maternal  infection  may  be  severe, 
scarcely  perceptible  or  remain  latent  and  after  years  appear  as  gum- 
mous  or  ulcerative  processes. 

Syphilitic  infection  may  be  carried  through  the  sperma  as  well  as 
through  the  placenta.  In  spermatic  infections,  the  fetus,  saturated 
with  lues,  may  infect  the  mother  or  the  infection  may  remain  latent  in 
the  fetal  system.     In  the  latter  case  the  mother  remains  healthy. 

Hereditary  syphilis  must  be  divided  into  early  hereditary  and 
retarded  hereditary  syphilis,  dependent  ijpon  the  amount  of  syphilitic 
virus,  the  infection  of  both  parents,  the  time  elapsing  from  infection 
and  the  morbid  intensity  of  the  virus. 

In  cases  of  paternal  syphilis  alone  we  more  frequently  find  syphilis 
hereditaria  tarda  manifesting  itself  even  as  late  as  the  thirtieth  year. 
The  symptoms  are  then  of  the  tertiary  type. 

Manifestations  of  hereditary  syphilis  are  more  frequently  found  at 
birth  and  during  childhood. 

Among  the  various  evidences  of  hereditary  syphilis  are:  peculiar 
corneal  inflammations  often  preceded  by  articular  troubles ;  Hutchinson 
teeth;  retinal  and  choroidal  troubles;  modifications   in*  the  auditory 


136  ORIGINAL  ABSTRACTS. 

apparatus ;  various  cerebral  changes,  as  Jacksonian  epilepsy  or  general 
convulsions,  softening  from  endoarteritis,  infantile  hemiplegia,  hydro- 
cephalus and  idiocy;  various  pathological  conditions  of  the  skin, 
mucous  membranes,  bones  and  other  organs. 

The  prophylactic  treatment  should  be  directed  through  both  parents 
supplementary  to  treatment  already  taken.  This  consists  of  six  months 
of  mercurial  and  iodic  treatment  before  procreating  and  the  same 
treatment  would  better  be  continued  to  the  mother  through  her  ges- 
tation. J.  F.  B. 

NEUROLOGY. 

By  DAVID  INGLIS,  M.  D.,  Detroit,  Michigan. 

PKOVBSSOR  OP  NBRYOUS  AND  MBNTAL  OISBASKS  IN  THK  DSTKOIT  COLLBCB  OP  MBOICINB. 

AND 

IRWIN  HOFFMAN  NEFF,  M.  D..  Pontiac.  Michigan. 

ASSISTANT  PHYSICIAN  AT  THB   BASTBBN   MICHIGAN  ASYLUM. 


THE  EARLY  OCULAR  SIGNS  OF  DEMENTIA  PARALYTICA. 

HoLDEN  {Journal  of  Nervous  and  Mental  Disease,  November, 
1905,  Volume  XXXII,  Number  XI).  The  writer's  conclusions  are 
bounded  on  seventy  cases  of  paretic  dementia  which  he  believed  to  be 
uncomplicated,  that  is,  without  cord  involvement.  The  writer  believes 
that  by  selecting  these  early  cases,  unattended  with  tabes,  he  has  more 
nearly  arrived  at  the  condition  of  the  pupillary  reflex  in  paretic 
dementia.  It  is  interesting  to  note  that  optic  nerve  atrophy  was  not 
found  in  one  of  the  seventy  cases  reported,  the  author  stating  that  he 
has  found  pallor  of  the  optic  disc  only  when  symptoms  of  tabes  or  of 
nicotin  poisoning  complicate  the  cases  of  paretic  dementia. 

The  writer's  recapitulation  is  as  follows:  "As  this  table  shows, 
in  true,  uncomplicated  paresis  there  is  early  in  the  disease  almost 
constant  absence  of  the  sensory  reflex,  in  half  the  cases  irregularity 
of  the  pupils,  in  nearly  half  inequality  of  the  pupils,  in  more  than  half 
abnormally  small  pupils,  in  a  fifth  of  the  cases  loss  of  light  reaction, 
in  another  fifth  marked  sluggishness  of  light  reaction,  and  in  a  few 
of  those  with  diminished  light  reaction  a  diminution  of  convergence 
reaction  also."  i.  h.  n. 


PSYCHASTHENIA:    ITS  CLINICAL  ENTITY 
ILLUSTRATED  BY  A  CASE. 

Schwab  (Journal  of  Nervous  and  Mental  Disease^  November, 
1905,  Volume  XXXII,  Number  XI).  The  writer  quotes  Janet,  and 
while  corroborating  his  views,  is  inclined  to  think  that  Janet's  ideas  of 
combining  many  symptoms  and  giving  it  one  name  is  not  to  be  at 
present  commended.  He,  however,  believes  that  there  is  a  disease 
which  can  be  distinguished  from  hysteria  and  neurasthenia,  and  as 
illustrative  of  this  publishes  his  case,  with  the  detailed  clinical  history. 

I.    H.    N. 


! 

i  BALDNESS  AND  BREATHING.  137 


EDITORIAL  COMMENT. 


BALDNESS  ASCRIBED  TO  IMPROPER  BREATHING. 

Doctor  Delos  L.  Parker,  of  Detroit,  who  has  been  experimenting 
to  determine,  if  possible,  the  factors  leading  to  baldness,  deduces  some 
very  interesting  conclusions.  To  summarize,  the  entire  theory  is  based 
on  the  contention  that  air,  deposited  in  the  alveoli  of  the  lungs  which 
are  not  utilized  in  the  process  of  respiration,  develops,  in  the  presence 
of  warmth  and  moisture,  a  poison  which  the  investigator,  in  a  series  of 
preliminary  studies,  designated  trichotoxin.  The  substance  gaining 
entrance  to  the  circulatory  system,  attacks  the  hair  ( i )  by  toxic  effect, 
and  (2)  by  depositing  a  crust — dandruff — upon  the  cranial  cutis.  In 
experimentation,  Doctor  Parker  has  been  able  to  manufacture  the 
poison  artificially  by  gathering  exhaled  air  in  bottles — partially  filled 
with  water — and  subjecting  it  to  body  temperature.  By  shaking  the 
flasks  occasionally  the  proper  degree  of  moisture  is  maintained.  In  the 
course  of  four  or  five  days  the  water  is  evaporated  to  dryness  over  a 
water-bath,  and  a  residual  deposit,  closely  resembling  frost  on  a  window 
pane,  is  observed.  Microscopic  examination  discloses  a  crystalline 
structure  closely  resembling  uric  acid,  but  tests  demonstrate  the  absence 
of  this  product.  The  deposit  is  composed  of  two  substances,  one  of 
which  is  readily  soluble  in  absolute  alcohol.  By  allowing  the  alcohol, 
in  which  have  been  dissolved  some  of  the  crystals,  to  evaporate,  the  fact 
was  ascertained  that  the  insoluble  crystals  are  larger  than  the  soluble. 
Animal  experimentation  developed  some  interesting  features.  Injec- 
tions of  the  insoluble  crystals  resulted  in  loss  of  hair,  while  the  effect 
of  treatment,  with  the  soluble  crystals  was  merely  a  crust  or  scaly 
deposit  on  the  skin,  with  no  destruction  of  hair.  Doctor  Parker  con- 
cludes that  the  insoluble  product  is  the  direct  cause  of  baldness,  while 
the  soluble  product  is  the  cause  of  dandruff.  To  the  insoluble  substance 
the  term  trichotoxin — hair  poison — still  applies,  but  since  the  other 
substance  does  not  affect  the  hair,  but  does  affect  the  secretion  of  the 
sebaceous  glands,  the  sebum,  the  term  stearotoxin  (meaning  sebum 
poison)  has  been  originated  to  represent  it. 

In  order  to  have  the  alveoli  of  all  parts  of  the  lungs  utilized  for 
breathing  purposes,  and  the  conditions  that  permit  the  poison  of  bald- 
ness to  form  prevented  from  being  developed,  the  upper  ribs  must  rise 
and  fall  with  each  respiratory  act.  In  persons  not  bald  this  always 
occurs.  In  persons  affected  with  baldness  it  does  not  occur.  If  this  form 
of  breathing  is  practiced,  baldness  will  not  develop,  and  if  it  is  re-estab- 
lished and  carried  on  continuously  after  being  lost,  baldness  that  may 
have  resulted  from  its  absence  will  be  repaired. 

Doctor  Parker  intends  to  publish  an  extended  account  of  his  work 
in  the  near  future. 


138  EDITORIAL  COMMENT. 

MEDICINE  IX  POPULAR  MAGAZINES. 

The  importance  of  diffusing  sound  ideas  of  physiology  and  path- 
ology among  thinking  people  is  generally  accepted  among  those  who 
know.  How  difficult  it  is  to  secure  reception  for  truth,  and  how  easy 
to  spread  error,  are  both  only  too  well  known. 

A  recent  number  of  Current  Literature  illustrates  these  facts.  It 
contains  two  medical  articles.  One  is  on  the  subject  of  "Pneumonia, 
Mice,  and  the  Cold  Cure,"  and  will  probably  do  no  harm.  The  other 
is  entitled  "Extraction  of  Gastric  Juice  from  the  Live  Hog."  This 
opens  with  the  somewhat  illogical  statement  that  "Natural  gastric 
juice  is  so  essential  to  the  development  of  therapeutic  science  that  the 
supply  of  the  fluid  threatens  to  be  inadequate  to  meet  the  demand." 
Just  what  this  means  the  writer  may  know,  but  how  well  qualified  he 
is  for  taking  up  such  a  subject  can  be  gathered  from  the  next  sen- 
tence, about  as  absurd  and  groundless  as  can  be  imagined :  "In  pul- 
monary tuberculosis  the  use  of  the  natural  gastric  juice  from  an 
extraneous  source  has  been  held  a  condition  precedent  to  cure."  Put 
in  simple  language  this  can  hardly  mean  anything  else  than  that  gastric 
juice  must  be  given  to  patients  with  pulmonary  tuberculosis,  if  they 
are  to  be  healed.  Perhaps  some  may  have  "held"  this  view,  but  how 
remote  it  is  from  modern  medicine  needs  no  remark.  The  article  then 
quotes  a  newspaperese  account  of  gastric  fistula  operations  on  pigs, 
with  side-tracking  of  the  stomach,  ending:  "When  gastric  juice  is  to 
be  extracted,  the  hogs  are  raised  into  the  air."  If  true,  the  animals 
would  be  in  the  same  element  as  the  abstracter's  ideas. 

The  question  naturally  arises.  If  the  editorial  omniscience  is  as 
faulty  in  matters  of  literature,  politics,  and  art,  what  sort  of  an  authority 
or  guide  is  the  periodical? 


A  RECORD  OF  THE  HEAT  INTENSITY  OF  RADIUM. 

The  investigations  of  the  Swedish  scientist.  Angstrom,  to  deter- 
mine the  amount  of  heat  evoluted  by  the  product  radium,  are  of  suffi- 
cient importance  to  arouse  medical  interest.  The  research  of  this 
worker  demonstrates  that  the  heat  evolutions  remain  practically  con- 
stant for  a  year,  regardless  of  the  nature  of  the  surrounding  medium, 
and  accordingly  the  conclusion  is  reached  that  the  beta  and  gamma 
rays  form  but  an  insignificant  part  of  the  total  energy  of  the  metal. 
The  apparatus  and  method  of  determining  the  amount  of  heat  evoluted 
were  indeed  simple.  Radium  bromid — 86.5  milligrams — was  encased 
in  a  small  metal  cylinder,  in  close  proximity  to  a  second  cylinder  of 
similar  construction,  which  contained  a  small  manganine  coil  charged 
with  an  electrical  current.  Accurate  measurement  of  the  heat  evolu- 
tions of  the  two  cylinders  was  recorded  by  means  of  thermoelements. 
The  cylinder  containing  the  coil  was  kept  at  a  temperature  identical 
with  that  containing  the  radium,  by  varying  the  current  traversing  the 


LIVE  BABES  FROM  SUBJECTS  OK  LUES.  139 

manganine  coil,  and  in  order  to  obviate  error  in  measurement  due  to 
a  possible  metallic  difference  in  the  cylinders  alternation  was  resorted 
to.  The  character  of  the  metal  employed  in  the  cylinders  apparently 
exerted  little  influence  in  the  result  obtained  since  the  amount  of  heat 
was  found  to  be  1.136  small  calories  per  minute  for  each  gram  of  the 
metal  employed,  whether  lead,  copper,  or  aluminium  cylinders  were 
utilized.  The  radium  product  investigated  by  Angstrom  from  Septem- 
ber, 1903,  to  January,  1905,  evidenced  no  apparent  alteration  in  the 
amount  of  heat  evoluted.  The  heat  effect  of  the  metal  would  therefore 
seem  to  be  due  to  the  internal  activity  of  the  alpha  particles,  or  to  some 
agent  which  is  decidedly  different  in  character  from  the  trio  of  rays 
mentioned. 


ANNOTATIONS, 


OCCULT  THERAPY  IN  THE  OTTOMAN  EMPIRE. 

Even  somnolent  and  superstitious  Turkey  is  awakening  to  a  reali- 
zation of  the  fraud  that  is  perpetrated  by  unscrupulous  medical  prac- 
titioners, and  a  crusade  against  quackery  of  all  kinds  is  now  being 
agitated.  Although  the  people  in  general  are  vastly  too  ignorant  to 
appreciate  skilled  medical  attendance,  reputable  practitioners  are  at  last 
aroused  to  action.  As  elsewhere,  the  quacks  of  the  Empire  flourish  by 
grossly  deceiving  the  masses,  most  diseases  being  ascribed  to  the 
malefactions  of  an  evil  eye,  while  occult  therapy  largely  constitutes  the 
system  of  practice. 

INSECTS  AS  SPREADERS  OF  INFECTION. 

Meyer,  a  German  physician,  has  conducted  experiments  with  ants 
to  determine  the  alacrity  with  which  the  insects  carry  disease  germs. 
Some  mice  infected  with  typhoid  were  placed  in  a  cage  to  which  a 
colony  of  ants  had  ready  access.  A  second  cage  containing  uninocu- 
lated  mice  was  placed  so  that  the  ants  could  gain  entrance.  Shortly 
the  uninfected  mice  were  perceived  to  develop  all  the  symptoms  of  the 
disease.  Plates  of  media  over  which  the  ants  ran  developed  mouse 
typhoid  in  pure  culture,  and  the  fact  that  the  insects  can  carry  infec- 
tion effectively  was  evidenced  when  the  investigator  himself  became 
ill  with  the  disease. 


LIVE  BABES  FROM  PREGNANT  SUBJECTS  OF  LUES. 

Gaucher  announces  a  treatment  for  syphilitic  pregnant  women 
which  is  calculated  to  insure  a  live,  well-developed  infant  at  full  term. 
Essentially,  an  important  factor  is  the  establishment  of  treatment 
during  the  early  stages  of  pregnancy.  Mercury,  the  old  specific  sheet- 
anchor,  is  the  remedy,  but  especial  stress  is  placed  on  the  fact  that  a 


140  MEDICAL  NEWS. 

readily  absorbable  preparation  must  be  employed.  Sublimate  in  pill 
form  for  ingestion,  and  benzoate  of  mercury  in  alkaline  solution  for 
subcutaneous  injection,  are  prescribed.  Of  sublimate,  a  centigram  is 
administered,  with  a  like  amount  of  extract  of  thebane,  twice  daily. 
The  benzoate  is  employed  in  injections  of  two  centigrams,  once  daily. 
The  ideal  treatment  contemplates  alternation,  giving  the  sublimate  one 
day  and  the  benzoate  the  next,  permitting  frequent  rests  from  treat- 
ment during  the  pregnant  state.  In  albuminuric  conditions  the  dose  by 
injection  should  be  decreased  one-half,  and  when  elimination  is  faulty 
the  tannate  of  mercury,  two  to  ten  centigrams,  must  succeed  a  period  of 
milk  diet. 


MEDICAL  NEWS. 


AMERICAN  MEDICINE  BECOMES  A  MONTHLY. 

Doctor  George  M.  Gould  has  announced  the  transformation  of 
American  Medicine  from  a  weekly  into  a  monthly  publication.  At  a 
recent  meeting  of  the  stockholders  there  was  an  overwhelming  senti- 
ment in  favor  of  certain  changes  of  policy,  and  the  directors  of  the  cor- 
poration were  constituted  a  committee  to  inaugurate  such  changes  as 
might  seem  indics^ted  after  due  deliberation.  A  new  series  monthly  is 
an  innovation  contemplated  in  the  new  policy.  After  giving  assurance 
that  the  present  "scientific,  professional,  and  literary  standards"  of  the 
weekly  will  be  maintained  in  the  monthly,  the  editor  has  this  to  say: 

"The  cause  of  independent  medical  journalism  is  growing  more 
important  each  year,  and  recognition  of  its  value  and  necessity  is  becom- 
ing more  general  in  the  profession.  The  professionally-owned  journal 
conducted  in  the  interests  of  untrammeled  opinion  and  speech,  usually 
the  sole  medium  of  expression  for  the  minorities  through  whom  progress 
has  always  come,  must  necessarily  encounter  more  difficulties  than  those 
periodicals  which  represent  interests  solely  commercial,  or  are  the 
mouthpieces  of  societies  or  other  organizations,  whether  great  or  small. 
It  is  a  matter  for  congratulation  that  there  is  always  an  emergence  from 
such  conditions  into  greater  freedom  and  progress.  Experience  has 
shown,  moreover,  that  most  of  what  is  best  worth  while  in  the  profes- 
sion has  been  accomplished  through  the  efforts  of  independent  profes- 
sional journals,  though  too  frequently  the  final  details  of  the  measures 
they  have  inspired  or  inaugurated  must  be  left  to  the  publications  which, 
representing  large  professional  bodies  and  hence  more  powerful  finan- 
cially, deal  naturally  with  measures  which  have  become  popularized  and 
thus  represent  "majority"  views.  The  profession  is  vitally  concerned 
in  the  existence  and  power  of  its  professionally-owned  medical  journals, 
and  a  large  part  of  this  interest  must  be  directed,  if  it  is  foresighted  and 
wise,  to  the  cause  of  the  independent  medical  journal.  No  efforts  should 
be  spared  to  make  recognition  of  these  facts  more  general." 


MINOR    INTELLIGENCE.  141 

MINOR  INTELLIGENCE. 

The  Illinois  Medical  College  is  a  beneficiary  in  the  will  of  the  late 
Doctor  Addison  H.  Foster,  a  prominent  Chicago  physician,  who 
bequeathed  his  valuable  library  to  the  institution. 

Doctor  Leonard  Lawshe  Skelton,  professor  of  neurology  and 
psychiatry  in  the  Illinois  Medical  College,  died  at  his  home  in  Chicago 
on  March  14,  aged  forty-three  years.  Doctor  Skelton  was  graduated 
from  Northwestern  University  in  1885. 

Ballard,  Washington,  is  to  have  a  new  hospital  for  the  treatment 
of  tuberculosis,  smallpox  and  other  contagious  diseases.  The  projectors 
have  organized  a  company,  the  capital  stock  of  which  is  $100,000,  and 
the  plans  contemplate  a  magnificent  main  building. 

The  path  of  mystic  medicine  does  not  seem  to  be  strewn  with  roses 
in  any  section  of  the  country.  A  "mental  healer"  was  recently  con- 
victed at  Sea  Breeze,  Florida,  after  a  trial  lasting  twelve  days,  and 
sentenced  to  pay  a  fine  of  $500  and  serve  thirty  days  in  jail. 

Out  of  five  hundred  volunteers,  one  hundred  physicians  have  been 
chosen  as  subjects  for  experimentation  by  the  Anti-Seasick  League, 
which  meets  in  Lisbon  during  April.  Various  remedies  for  the  affec- 
tion will  be  tested,  and  a  special  steamer  has  been  chartered  that  prac- 
tical demonstration  may  be  made. 

Revocation  of  the  charters  of  several  of  the  transit  companies  oper- 
ating in  the  Borough  of  Manhattan  is  threatened.  The  cars,  besides 
being  of  an  antique  design,  are  said  to  positively  reek  with  filth.  Since 
they  have  not  been  painted  in  years,  and  are  generally  in  a  very  dilapi- 
dated condition,  they  are  hygienically  and  otherwise  a  menace  to  health 
and  limb. 

Carmen  Sylva,  in  an  article  on  "The  Jews  in  Roumania,"  comes 
to  the  defense  of  her  countrymen  in  their  treatment  of  the  Jews,  by 
proclaiming  that  they  are  not  inhospitable,  but  utterly  poverty-stricken. 
She  argues  that  the  country's  wealth  is  not  sufficient  for  the  support  of 
foreigners  and  that  her  own  people  are  barely  able  to  obtain  an 
existence. 

The  suit  instituted  by  a  contagious-disease  patient  against  the  Pull- 
man Car  Company,  to  recover  damages  sustained  by  being  refused 
admittance  to  a  passenger  coach,  has  been  won  by  the  company,  the 
Supreme  Court  of  Alabama  contending  that  the  operators  of  car  sys- 
tems have  the  right  to  exclude  persons  suffering  from  contagious  and 
infectious  diseases. 

A  BILL  has  been  introduced  in  the  New  York  legislature  which  pro- 
vides for  the  creation  of  a  state  commission  to  regulate  the  practice  of 
nursing.  The  measure  provides  for  a  commissioner  and  deputy,  whose 
salaries  shall  be  $7,500  and  $4,500  respectively;  a  secretary,  whose 
salary  shall  be  $4,000 ;  and  a  board  of  physicians.  It  is  intended  that 
the  fees  of  applicants  shall  cover  the  salary  expenditure. 


142  MEDICAl,  NEWS. 

Professor  von  Behring,  whose  startling  declaration  that  he  had 
discovered  a  cure  for  tuberculosis  was  published  some  time  ago, 
recently  stated,  in  an  address  at  Berlin,  that  the  milk  of  immunized 
cows  is  a  specific  for  the  disease.  Has  the  doctor  unearthed  two  cures, 
or  has  the  therapy  of  his  first  alleged  remedy  inadvertently  leaked  out? 

The  Mississippi  legislature  recently  defeated  a  bill  to  compel  com- 
pounders of  proprietary  and  patent  medicines  to  divulge  their  formulae. 
Druggists  of  the  state  strongly  denounced  the  measure  as  detrimental 
to  their  interests,  inasmuch  as  its  passage  would  necessitate  the  publi- 
cation of  formulae  which  had  taken  years  of  experience  to  perfect. 

Heidelberg  is  to  have  a  new  Cancer  Institute,  and  in  connection 
with  its  opening  next  September,  an  International  Congress  of  Cancrol- 
ogy  will  be  held.  The  local  authorities  are  pledged  to  furnish  funds  for 
the  maintenance  of  the  institution  for  fifty  years.  Nearly  $200,000  has 
already  been  subscribed.  Czerny,  chief  of  the  surgical  staff  at  Heidel- 
berg, has  resigned  that  post  and  will  henceforth  devote  his  energies  to 
cancer  research. 

Paul  C.  Freer,  M.  D.,  Pii.  D.,  who  until  recently  occupied  the 
chair  of  chemistry  at  the  University  of  Michigan,  is  now  editor-in- 
chief  of  The  Philippine  Journal  of  Science,  the  first  number  of  which 
has  made  its  appearance.  The  publication  is  issued  by  the  Bureau  of 
Science  and  will  chronicle  the  researches  of  the  profession  in  the  Philip- 
pines, dealing  especially  with  problems  involving  bacteriology,  immunity 
and  tropical  diseases. 

Twenty-five  thousand  dollars  has  been  set  aside  by  the  trustees  of 
Montefoire  Hospital  and  Home  for  Chronic  Invalids,  in  New  York 
City,  for  the  assistance  of  former  patients  of  the  institution  who  have 
either  been  cured  or  permanently  relieved,  the  interest  accruing  from 
the  amount  being  utilized  for  the  purpose.  Patients  at  the  county 
branch  of  the  institution — the  Bedford  Sanitarium  for  Consumptives — 
are  included  among  the  beneficiaries  of  the  fund. 

The  equipment  of  the  Craig  Colony  for  Epileptics  is  to  be  aug- 
mented by  the  construction  of  five  additional  cottages,  contracts  for 
which  have  recently  been  signed.  When  the  structures  are  completed 
and  occupied  the  colony  will  comprise  about  one  thousand  two  hundred 
fifty  patients.  A  bill  is  pending  in  the  legislature  for  the  appropriation 
of  $300,000,  for  the  construction  of  new  buildings,  and  in  the  event  of 
its  passage  the  colony  will  be  increased  to  eighteen  hundred  persons. 

**The  name  Carnrick  has  for  nearly  half  a  century  been  a  sufficient 
guarantee  to  medical  men  of  the  ethical  status  of  their  preparations/* 
The  foregoing  announcement  has  been  circulated  by  an  Eastern  con- 
cern presumably  with  the  idea  of  gaining  prestige,  but  an  advertise- 
ment in  the  last  number  of  this  journal  advises  the  profession  that  the 
instigator  of  the  above  quotation  is  not  identified  with  the  pioneer  pharm- 
aceutic firm  of  Reed  &  Carnrick,  who  assume  responsibility  for  their 
own  products  solely. 


ACUTE  CONTAGIOUS  DISKASES.  143 

RECENT  LITERATURE. 


REVIEWS. 

OPERATIVE  SURGERY.* 

The  fourth  revised  edition  of  this  valuable  work  is  now  on  sale. 
Many  improvements  are  noticeable  in  the  illustrations.  A  number  of 
new  ones  are  introduced,  and  many  of  the  old  ones  have  been  changed 
to  conform  to  modern  conceptions.  The  greatest  changes  are  found  in 
the  second  volume.  One  finds  described  here  by  text  and  illustration 
the  latest  methods  of  performing  intestinal  anastomosis,  gastroenter- 
ostomy, pylorectomy,  and  many  other  new  and  important  operations 
in  the  upper  abdomen.  One  has  only  to  read  a  chapter  here  and  there 
to  be  convinced  that  the  book  is  modernized. 

We  take  pleasure  in  introducing  it  to  our  friends  who  do  surgery 
because  they  can  secure  accurate  knowledge  frorn  it,  and  to  those  who 
read  surgery  because  of  its  charming  Myle.  c.  c.  d. 

*By  Joseph  D.  Bryant,  M.  D.,  Professor  of  the  Principles  and 
Practice  of  Surgery,  Operative  and  Clinical  Surgery,  in  the  University 
and  Bellevue  Hospital  Medical  College;  Visiting  Surgeon  to  Bellevue 
and  Saint  Vincent's  Hospitals ;  Consulting  Surgeon  to  the  Hospital  for 
Ruptured  and  Crippled,  Woman's  Hospital,  and  Manhattan  State 
Hospital  for  the  Insane,  et  cetera. 


ACUTE  CONTAGIOUS  DISEASES.* 

The  authors  have  given  to  the  profession  a  work  that  has  long 
been  needed.  We  feel  that  in  recommending  it  to  our  readers  we 
are  only  doing  our  duty.  It  should  be  in  the  hands  of  every  health 
officer  and  of  those  who  have  much  to  do  with  the  acute  contagious 
disease*.  Every  important  phase  of  the  subject  is  fully  considered  by 
men  whose  years  of  experience  with  these  diseases  cannot  help  but 
enable  them  to  speak  with  authority.  It  is  a  book  that  should  be  read 
and  reread.  The  illustrations  are  the  best  that  have  been  produced. 
Those  who  have  had  experience  witjti  the  acute  contagious  diseases 
will  appreciate  them,  and  those  who  are  doubtful  of  the  characters  of 
the  closely  allied  eruptions  will  receive  much  help  from  a  critical 
differential  study  of  them. 

*A  Treatise  on  Acute  Contagious  Diseases.  By  William  M.  Welch, 
M.  D.,  Consulting  Physician  to  the  Municipal  Hospital  for  Contagious 
and  Infectious  Diseases;  Diagnostician  to  the  Bureau  of  Health,  et 
cetera,  Philadelphia,  and  Jay  F.  Schamberg,  A.  B.,  M.  D.,  Professor  of 
Dermatology  and  of  Infectious  Eruptive  Diseases,  Philadelphia  Poly- 
clinic ;  Consulting  Physician  to  the  Municipal  Hospital  for  Contagious 
and  Infectious  Diseases,  and  Assistant  Diagnostician  to  the  Philadelphia 


144  RECENT  LITERATURE. 

Bureau  of  Health,  et  cetera.  In  one  very  handsome  octavo  volume  of 
781  pages,  illustrated  with  109  engravings  and  61  full-page  plates. 
Cloth,  $5.00,  net;  leather,  $6.00,  net;  half  morocco,  $6.50,  net.  Lea 
Brothers  &  Company,  Publishers,  Philadelphia  and  New  York,  1905. 


INTERNATIONAL  CLINICS.* 

This  volume  keeps  up  the  excellent  record  made  by  Doctor  Kelly 
in  the  practical  series  it  represents.  Treatment,  Medicine,  Surgery, 
Obstetrics  and  Gynecology,  Ophthalmology  and  Pathology  are  the 
topics  for  this  number.  It  is  difficult  to  select  a  few  from  so  many 
articles — twenty-five  in  all — ^but  among  the  most  useful  for  the  general 
practitioner  may  be  named :  "The  Treatment  of  Some  Common  Gastric 
Disorders,"  by  Norman  B.  Gwyn ;  "Empyema,  with  a  Report  of  Thirty 
Cases,"  by  J.  N.  Hall ;  "The  Later  Stages  of  Cirrhosis  of  the  Liver,"  by 
Sir  Dyce  Dickworth;  "The  Thyroid  Gland — Its  Anomalies  of  Secretion 
and  their  Manifestations  and  Treatment,"  by  Thomas  R.  Brown ;  "The 
Results  of  Operations  in  the  Treatment  of  Diseases  of  the  Stomach," 
by  John  B.  Deaver;  "Phlebitis,  Thrombosis  and  Embolism  Following 
Abdominal  and  Pelvic  Operations,"  by  William  A.  Edwards;  "The 
Etiology  and  Early  Diagnosis  of  Acute  Peritonitis,"  by  Benjamin  T. 
Tilton.  Charles  F.  Craig  has  a  very  thorough  paper  on  the  "Symptom- 
atology and  Diagnosis  of  Malta  Fever,"  and  Aldred  S.  Warthin  one  on 
"An  Experimental  Study  of  the  Effects  of  Rontgen  Rays  upon  the 
Blood-Forming  Organs,  with  Special  Reference  to  the  Treatment  of 
Leukemia."  As  before,  the  series  warmly  deserves  the  study  and 
support  of  the  profession. 

*A  Quarterly  of  Illustrated  Clinical  Lectures  and  Especially  Pre- 
pared Articles,  et  cetera,  et  cetera.  Edited  by  A.  O.  J.  Kelly,  A.  M., 
M.  D.  Volume  IV.  Fifteenth  Series.  1906.  Philadelphia  and  London : 
J.  B.  Lippincott  Company,  1906. 


THE  PRACTITIONER'S  VISITING  LIST.* 

This  book  is  well  adapted   to  make  a  physician's  book-keeping 
reliable  and  accurate.    It  is  complete  in  every  respect. 
*Lea  Brothers  &  Company,  1906. 


PROGRESSIVE  MEDICINE.* 

Progressive  Medicine  for  June,  1905,  contains  the  following 
subjects:  Hernia;  Surgery  of  the  Abdomen  Exclusive  of  Hernia; 
Gynaecology ;  Diseases  of  the  Blood ;  Diathetic  and  Metabolic  Diseases ; 
EHseases  of  the  Spleen,  Thyroid  Gland,  and  Lymphatic  System;  and 
Ophthalmolog}'.  Each  section  brings  into  convenient  form  the  year's 
work  on  the  lines  indicated.  A  comprehensive  index  makes  the  book 
valuable  for  rapid  reference. 

*Lea  Brothers  &  Company,  Philadelphia  and  New  York. 


%  ite^ian  anlr  Surgeon 

A  PROFESSIONAL  MEDICAL  JOURNAL. 


VOLUME  XXVIII.  APRIL,  1906.  NUMBER  IV. 


ORIGINAL  ARTICLES- 


MEMOIRS. 


PATHOLOGIC  PHYSIOLOGY  OF  THE  TRACTUS 

GENITALIS. 

By  BYRON  ROBINSON,  B.  S.,  M.  D.,  Chicago,  Illinois. 

PROPBSSOR   OF  CYNKCOLOGV   AND   ABDOMINAL  SURGBKY   OF  WOMBN  IN  THB   ILLINOIS  MEDICAL   COLLBGB. 

For  over  a  decade  I  have  been  attempting  to  make  prominent  in 
gynecologic  teaching,  pathologic  physiology,  disordered  function, 
rather  than  pathologic  anatomy,  changed  structure.  It  seems  to  me 
that  disorder-functions  or  pathologic  physiology  of  the  tractus  geni- 
talis impresses  itself  more  indelibly  on  the  student's  and  practitioner's 
mind  than  pathologic  anatomy.  Besides,  in  gynecologic  practice  patho- 
logic physiology  occurs  tenfold  more  frequently  in  the  genital  tract  than 
pathologic  anatomy.  For  the  gynecologist  pathologic  physiology  pre- 
sents innumerable  views  of  practical  interest.  Pathologic  physiology 
teaches  that  the  circulation  of  an  organ  is  a  fundamental  factor  in  com- 
prehending its  disease  and  administering  rational  treatment.  It  takes  an 
inventory  of  the  volume  of  blood  which  streams  through  the  organ  as  a 
fundamental  factor  in  comprehending  its  diseases  and  administering 
rational  treatment.  It  takes  an  inventory  of  the  volume  of  the  blood 
which  streams  through  the  organs  at  different  stages  and  conditions. 
We  wrote  years  ago  that  the  arteries  of  different  viscera  were  supplied 
with  automatic  visceral  ganglia,  and  we  christened  the  peculiar  nerve 
nodes  found  in  the  walls  and  adjacent  to  the  uterus,  oviducts  and 
ovaries,  as  "Automatic  Menstrual  Ganglia."  The  automatic  menstrual 
ganglia  complicates  the  blood  supply  oi  the  tractus  genitalis  by  chang- 
ing its  volume  during  the  different  sexual  phases.  In  pueritas  the 
blood  stream  of  the  tractus  genitalis  is  quiescent  as  well  as  its  paren- 
ch>Tnatous  cells;  in  pubertas  it  is  developing  as  well  as  proliferating 
parenchymatous  cells.  In  menstruation  the  blood  stream  is  active  with 
active  parenchymatous  cells.     In  the  puerperium  there  is  retrogression 


146  ORIGINAL  ARTICLES. 

of  blood  stream  and  an  involution  of  parenchymatous  cells.  The 
climacterium  is  the  opposite  of  pubertas — subsidence,  the  decrease 
of  blood  volume  and  parenchymatous  cells.  Senescence  is  a  repetition 
of  pueritas — the  quiescence  of  the  genitals,  their  long  night  of  rest. 
The  circulation  of  an  organ  quotes  its  value  in  the  animal  economy. 
It  rates  its  function.  Observe  the  enormous  volume  of  blood  passing 
through  the  kidney  or  pregnant  uterus  in  a  minute. 

To  study  pathologic  physiology  of  any  visceral  tract  we  iViust 
possess  clear  views  as  to  its  physiology.  The  physiology  of  the  tractus 
genitalis  is:  (i)  Ovulation;  (2)  peristalsis;  (3)  secretion;  (4) 
absorption;  (5)  menstruation;  (6)  gestation;  (7)  sensation. 

(i)  On  account  of  the  numerous  theoretic  views  connected  with 
Ovulation  and  lack  of  space  we  will  omit  the  general  discussion  on 
the  pathologic  physiology  of  ovulation.  It  is  well  known  that  ovulation 
has  a  wide  physiologic  range.  We  do  not  know  the  life  of  an  ovum 
or  corpus  luteum.  It  was  once  supposed  that  a  corpus  luteum  was  a 
sign  of  pregnancy  and  the  supposition  gained  legal  or  judicial  position. 
We  know  that  this  is  an  error.  I  have  found  two  corpora  lutea  on  one 
ovary  of  a  lamb  which  had  not  been  pregnant.  The  internal  secretion 
of  the  ovary  is  important  and  chiefly  manifest  by  marked  symptoms 
on  removal  of  both  ovaries — neurosis,  accumulation  of  panniculus 
adiposus,  extra  growth  of  hair,  diminished  energy  and  ambition.  These 
symptoms  may  occur  in  women  possessing  both  ovaries,  hence,  we 
would  conclude  that  pathologic  physiology  of  ovarian  secretion  existed. 
The  sensation  of  the  ovary  occupies  a  wide  zone  of  pathologic  physi- 
ology in  the  mental  and  physical  being.  Forty  per  cent  of  women 
visiting  my  office  remark,  "I  have  pain  in  my  ovaries."  On  physical 
examination  we  find  the  following  conditions:  First  and  fore- 
most in  the  vast  majority  of  women  who  complain  of  pain  in  the 
ovaries  palpation  of  the  ovaries  elicits  no  tenderness  on  pressure. 
However,  the  pain  of  such  women  is  located  bilaterally  in  the  area 
of  the  cutaneous  distribution  of  the  ileohypogastric  and  ileoin- 
guinal  nerves.  It  is  a  skin  hyperesthesia — a  cutaneous  neurosis. 
The  bilateral  iliac  region  of  cutaneous  hyperesthesia  corresponds  to  the 
segmentation  or  somatic  visceral  (ovarian)  area,  and  presents  a  fre- 
quent varying  zone  of  sensory  pathologic  physiology.  In  the  vast 
majority  of  women  complaining  of  ovarian  pain  no  disease  of  the  ovary 
can  be  detected — it  is  cutaneous  hyperesthesia  of  the  ileoinguinal  and 
ileohypogastric  nerves. 

(2)   Peristalsis  (excessive,  deficient,  disproportionate). 

(a)  Excessive  peristalsis  of  the  tractus  gentalis  (uterus  and 
oviducts)  may  occur  at  menstruation,  during  gestation,  parturition  by 
the  presence  of  myomata,  during  the  expulsion  of  blood  coagula, 
placenta  during  congestion.  The  phenomena  of  peristalsis  in  the 
uterus  and  oviduct  differs  from  the  form  and  distribution  of  the  mus- 
cularis.  The  myometrium  during  gestation  is  in  continual  peristalsis — 
uterine  unrest.     By  placing  the  hand  on  the  abdomen  of  a  four-month 


TRACTUS  GENITALIS. 


147 


FIGURE  I.— SYMPATHETIC    NERVES    SHOWING    THE    ORIGIN    OF^iTHE 

GENITAL  NERVES. 

S,  abdominal  brain :  B, showing  oriirin  of  Hpermatic  (ovarian) ;  F,  shows  origin  of  right  genital 
nerve  on  the  spermatic  (ovarian  artery) ;  J,  presents  the  plexus  intenliacus  which  orig- 
inates in  the  plexus  aorticus.  This  illustration  was  drawn  with  extreme  care  from  a 
sperimf^n  which  I  dissect^Mi  under  alcohol.  It  presents  what  I  call  the  swan-shaped 
ureters  which  are  diluted  and  prevents  ureteral  valves  (V).  IV,  presents  the  anastomosis 
of  the  plexus  ureteritis  with  the  plexus  spermaticus  (ovaricus). 


148  ORIGINAL  ARTICLES. 

gestating  woman  one  can  feel  the  uterine  muscular  waves.  The  ges- 
tating  uterus  is  always  prepared  for  an  abortion  but  the  cervix,  the  sen- 
tinel on  guard,  checks  the  proceeding.  Fright  will  produce  such  violent, 
disordered  myometrial  peristalsis  as  to  break  through  the  guarding 
cervix.  Many  women  during  gestation  experience  considerable  pain 
(supersensitive  uterus)  from  excessive  uterine  peristalsis — it  is  patho- 
logic physiology.  Uterine  peristalsis  may  be  sufficiently  excessive  to 
rupture  the  myometrial  wall.  The  "after-pains,"  puerperal  pains,  is 
excessive  peristalsis  in  an  infected  myometrium.  Frequently  the  severe 
pelvic  pain  during  menstruation  is  excessive  uterine  and  oviductal  peris- 
talsis due  to  its  extramenstrual  blood  supply.  It  is  chiefly  the  exces- 
sive peristalsis  at  menstruation  that  forces  many  women  to  assume  rest 
in  bed,  for,  with  anatomic  rest  (maximum  quietude  of  bones  and  volun- 
tary muscles)  and  physiologic  rest  (maximum  quietude  of  visceral 
muscles)  the  uterine  peristalsis  will  exist  at  a  minimum.  Excessive 
oviductal  peristalsis  may  produce  pain  of  varying  degrees.  In  exces- 
sive peristalsis  the  automatic  menstrual  ganglia  are  stimulated  by  extra 
quantities  of  blood  or  by  other  irritation. 

(b)  Deficient  peristalsis  of  the  tractus  genitalis  (uterus  and  ovi- 
ducts) is  not  uncommon.  Uterine  inertia  is  an  example  known  to 
every  obstetrician.  Deficient  uterine  peristalsis  allows  hemorrhage  in 
the  fourth  and  fifth  decades  of  woman's  life.  Deficient  peristalsis 
allows  extraglandular  secretion  (leucorrhea). 

(c)  Disproportionate  peristalsis  is  disordered,  wild  muscular  move- 
ments in  different  segments  of  the  uterus  or  oviduct. 

(3)   Secretion  (excessive,  deficient,  disproportionate). 

(d)  Excessive  secretion  from  the  genital  tract,  pregnant  or  non- 
pregnant, has  an  extensive  range  and  varying  quantity.  The  excessive 
secretion  zone  in  the  tractus  genitalis  has  an  important  bearing  in  prac- 
tice. Typical  pathologic  physiology  may  be  observed  in  the  pregnant 
woman  from  whose  uterus  may  flow  several  ounces  of  white  mucus 
daily — no  pathologic  anatomy  is  detectable.  Excessive  uterine  secretion  is 
a  common  gynecologic  matter.  The  glands  may  not  be  embraced  suffi- 
ciently firm  by  the  myometrium.  The  automatic  menstrual  ganglia  are 
diseased,  insufficiently  supplied  by  blood  or  the  myometrium  is  degen- 
erated. Flaccid  uteri  secrete  excessively.  Excessive  secretion  and  its 
Muid  currents  allows  insufficient  time  for  localization  of  the  ovum. 
Excessive  uterine  secretion  is,  from  apt  bacterial  media,  liable  to  become 
infected.  During  excessive  secretion  physical  examination  frequently 
detects  no  palpable  pathologic  anatomy — merely  physiology  has 
exceeded  its  usual  bounds. 

(e)  Deficient  secretion  of  the  tractus  genitalis  is  not  so  manifest  as 
its  opposite.  The  mucosa  of  vagina  and  uterus  present  excessive  dry- 
ness, dessication,  practically  as  visceral  functions  are  executed  by  means 
of  fluids,  pathologic  physiology  is  in  evidence ;  dryness  and  abrasion  of 
the  mucosa,  local  irritation,  chafing,  local  bacterial  development,  dys- 
parunia,  dysuria,  defective  import  of  spermatozoa  and  export  of  ova 


TRACTUS  GENITALIS. 


149 


FIGURE  IT.--PP:LVIC  BRAIN  (Adult). 


Drawn  from  my  o-wn  disnection.  A,  pelvic  brain.  In  this  cane  it  is  a  ganRlionat^'d  plexus  pos- 
sessing a  wide  meshwork.  Also  the  pelvic  brain  is  located  well  on  the  vagina,  and  the 
visceral  sacral  nerves  (pelvic  splanchnics)  are  markedly  elongated;  V,  vagina;  B,  blad- 
der; O,  oviduct;  Ut,  uterus;  Ur,  uret^-r ;  R,  rectum ;  P  L,  plexus  interiliacus  (left) ;  P  R, 
plexu.sint«riliacus  (right);  N,  sacral  ganglia;  Ur,  uret^^r:  5  L,  last  lumbar  nerve;  i,  ii, 
ili,  iv,  sacral  nerves;  5,  coccygeal  nerve.  Observe  that  the  great  vesical  nerve  (P)  arises 
from  a  loop  l)etween  the  ii  and  iii  satjral  nerves.    G  S,  great  sciatic  nerve. 


150  ORIGINAL  ARTICLES 

ending  in  sterility.  Deficient  secretion  means  that  waste-laden  fluids 
are  bathing  and  irritating  the  thousands  of  lymph  channels  in  the  body. 
Deficient  secretion  or  excessive  dryness  of  the  genital  mucosa — ^patho- 
logic physiology  with  no  perceptible  pathologic  anatomy — is  not  uncom- 
mon iq  gynecologic  practice.  Oily  applications  to  subjects  with  deficient 
genital  secretion  may  be  required  for  protection  of  exposed  nerve  per- 
iphery as  abrasion,  fissure,  ulcers  and  also  for  relief. 

(f)  Disproportionate  secretion  may  occur  in  the  different  segments 
of  the  genital  tract,  unequal,  excessive,  deficient,  irregular. 

(4)  Absorption  (excessive,  deficient,  disproportionate). 

(g)  Excessive  absorption  presents  two  views,  namely,  a  dryness  of 
the  genital  mucosa  from  excessive  absorption  of  the  mucal  fluids.  This 
resembles  the  conditions  arising  in  deficient  secretion  of  the  genital  tract 
(see  e).  Again  the  mucosa  of  the  genital  tract  excessively  absorbs. 
Deleterious  substances  lying  on  its  mucosa — septic  or  toxic.  Excessive 
absorption  in  the  genital  tract  pathologic  physiology,  resembles  excess- 
ive absorption  and  conditions  in  other  localities  as  the  absorption  of 
poison  ivy,  lead,  arsenic  among  art  workers.  The  pathologic  physi- 
ology possesses  a  wide  range  for  some  experience  no  ill-effects  while 
others  are  severely  or  even  fatally  ill  from  absorption  of  same  substance 
under  similar  conditions. 

(h)  DeHcient  absorption  in  the  tractus  genitalis  produces  an  exces- 
sive discharge,  the  decomposition  of  which  lays  the  foundation  of  bac- 
terial multiplication  and  excoriation  of  mucosa  and  skin. 

(i)  Disproportionate  absorption  occurs  in  the  different  segment  of 
the  tractus  genitalis  and  presents  pathologic  physiology.  However, 
lack  of  space  makes  it  impractical  to  discuss  it. 

(5)  Sensation   (excessive,  deficient,  disproportionate). 

(j)  Excessive  sensation  in  the  tractus  genitalis  presents  a  wide 
zone  of  pathologic  physiology.  Vaginismus  is  the  extreme  type  of 
genital  hyperesthesia.  The  introitus  vaginae  of  perhaps  fifty  per  cent 
of  women  is  supersensitive.  When  I  was  a  pupil  of  Mr.  Lawson  Tait 
he  had  a  patient,  a  recently  married  woman,  from  whom- the  husband 
was  sueing  for  divorce  as  her  genital  hyperesthesia  was  so  excessive  that 
coition  or  examination  was  intolerable.  She  had  to  be  anesthetized  to 
be  examined,  which  was  also  suggested  for  impregnation  with  the  hope 
that  gestation  would  relieve  the  condition.  Supersensitiveness  of  the 
pudendum  is  not  an  uncommon  matter  in  gjnecologic  practice  and  with- 
out demonstrative  pathologic  anatomy.  The  pathologic  physiology  of 
excessive  sensation  in  the  tractus  genitalis  has  a  wide  range  of  variation 
and  degree  of  intensity,  goirie  subjects  may  be  afflicted  with  excessive 
sensation  in  the  pudendum  for  many  years.  The  excessive  sensitive 
genitals  may  be  manifest  in  the  uterus  or  ovaries.  A  small  number 
complain  of  tenderness  and  soreness  in  the  internal  genitals  which  can- 
not be  detected  as  pathologic  anatomy — simply  excessive  sensation. 
The  gestating  uterus  may  be  so  sensitive  that  it  disorders  adjacent  vis- 


TRACTUS  GENITALIS. 


151 


cera  by  reflexes.     The  treatment  of  subjects  with  excessive  genital 
sensation  requires  unlimited  time  with  continuous  patience. 

(k)  Deficieftt  sensation  of  the  tractus  genitalis  is  encountered. 
With  such  subjects  practically  no  orgasm  occurs  during  coition  to 
which  they  are  indifferent.  Practically  little  or  no  treatment  is  required. 


FIGURE  III.— HISTOLOGY  OF  PELVIC  BRAIN. 

A,  drawn  from  the  pelvic  brain  of  a  ^irl  Heventeen  years  of  age.  The  ganglion  cells  are  com- 
pletely develoi>ed.  B,  drawn  from  the  pelvic  brtdn  of  a  three  months'  normal  gestation. 
The  ganglion  cells  are  complet<»ly  developed.  Observe  the  enormous  mass  of  connective 
tissue  present.  C,  child  l}4  years  old.  A  nerve  process  courses  within  the  ganglion. 
Few  and  small  ganglion  cells  incompletely  developed.  D,  girl  1^  years  old.  A  nerve 
process  branches  and  reunites  it«elf  with  the  intercellular  substance.  B,  girl  0  years 
old.  The  ganglion  cells  are  presenting  development.  (Redrawn  after  Doctor  Babura 
Haahmoto). 

(1)  Disproportionate  sensation  in  the  genital  tract  is  irregular, 
indefinite,  disordered,  sensation  arising  and  disappearing  in  its  different 
segments  practically  without  reason  or  rhyme. 

{6)   Menstruation  (excessive,  deficient,  disproportionate). 

I  will  present  this  subject  through  a  clinical  patient.  Brief  remarks 
on  common  examples  of  pathologic  physiology  in  the  tractus  genitalis 


162  ORIGINAL  ARTICLES.  • 

will  suffice  to  illustrate  and  suggest.  As  the  most  apt  subject  to  illus- 
trate pathologic  physiology  in  the  tractus  genitalis  I  will  choose  that  of 
menstruation. 

To  illustrate  the  value  of  pathologic  physiology  and  the  methods  of 
teaching  it  we  will  place  a  gynecologic  patient  before  a  student  to  elicit 
clinical  data  in  reference  to  menstruation  as  landmarks  for  diagnosis. 
A  landmark  is  a  point  for  consideration  physiologic,  anatomic,  patho- 
logic. To  teach  gynecology-  we  should  instruct  by  means  of  disordered 
function  as  a  base.  Menstruation  is  the  first  practical  function  of  the 
genital  tract.  Hence  the  student  asks  in  menstruation  four  questions, 
namely:  (a)  How  old  were  you  when  the  monthly  flow  began?  The 
patient  may  answer:  eleven  (premature),  fifteen  (normal),  or  nine- 
teen (delayed)  years  of  age.  This  answer  presents  a  wide  range  of 
beginning  of  the  menstrual  function.  Now,  the  girl  who  begins  to 
menstruate  at  eleven  generally  represents  pathologic  physiology,  but 
not  pathologic  anatomy.  For  example,  the  girl  who  begins  at  eleven 
(menstratio  precox)  will  in  the  majority  of  cases  menstruate  profusely 
and  prolonged.  She  will  experience  a  late  climacterium.  An  early 
menstruation  indicates  a  late  climacterium.  Though  one  can  palpate 
practically  no  pathologic  anatomy,  the  tractus  genitalis  is  prematurely 
developed  at  eleven  years  of  age,  premature  in  dimension  (nerves, 
blood,  lymph,  parenchyma)  and  function  (menstruation,  gestation). 
The  blood  stream  to  the  genitals  is  prematurely  excessive,  the  auto- 
matic menstrual  ganglia  are  large  and  prematurely  active.  Her  men- 
strual life  is  accompanied  by  excessive  blood  supply  and  hemorrhage, 
disordered  function,  active  parenchymatous  cells,  prolonged  reproduc- 
tiveness.  It  is  pathologic  physiology,  exaggerated  function  but  practi- 
cally not  pathologic  anatomy.  The  girl  who  begins  at  fifteen  is  prac- 
tically normal  during  her  menstrual  life.  No  pathologic  anatomy  nor 
pathologic  physiology  is  manifest.  The  girl  who  begins  to  menstruate 
at  nineteen  (menstratio  retarda)  is  delayed  with  her  menstrual  func- 
tion ;  late  menstrual  appearance  means  early  climacterium ;  it  frequently 
indicates  amenorrhea  and  dysmenorrhea.  It  generally  means  defect- 
ive genital  blood  supply  and  limited  parenchymatous  cellular  activity. 
It  is  pathologic  physiology,  disordered  function,  limited  productiveness, 
but  frequently  no  palpable  pathologic  anatomy  presents.  .It  is  a  fact, 
however,  that  in  some  cases  atrophy  or  myometritis  is  palpable  patho- 
logic anatomy  and  should  not  be  confused  with  subjects  possessing 
pathologic  physiology. 

(b)  The  student  asks  the  patient:  Is  the  monthly  flow  regular? 
The  answer  may  be,  regular  or  irregular.  The  patient  with  irregular 
menstruation  is  afflicted  with  pathologic  physiology  but  no  pathologic 
anatomy  may  be  detected.  It  may  be  stated,  however,  that  the  auto- 
matic menstrual  ganglia  require  about  eighteen  months  of  vigorous 
blood  supply  to  become  sufiiciently  strong  and  established  to  act  regu- 
larly monthly.     The  same  condition  exists  in  the  automatic  vi-^ceral 


TRAC  rUS  GENITALIS. 


15S 


ganglia  ( Auerbach's  and  Billroth-Meissner's)  of  the  tractus  intestinalis 
of  a  child. 

(c)  The  student,  thirdly,  asks  the  patient:  Is  the  monthly  flow 
painful?  The  answer  may  be,  yes  or  no.  A  normal  menstruation 
should  be  painless.     Dysmenorrhea  or  painful  menstruation  is  patho- 


KIGURE  IV.— SYMPATHETIC  NERVES. 

Dii«t*ctt^d  with  extrt^me  care  under  al(!ohol,  showinjc  origin  of  the  genital  nerves  flroni  the 
abdominal  brain,  from  the  plexu-s  ovaricus  O  on  the  right,  and  from  the  plexu.s  ovaricua  P 
on  the  left.  On  the  right,  M  pre.sents  the  anastomosis  of  the  plexus  uret^'ris  with  the 
plexus  ovaricus.  Ph  is  the  plexus  interiliacus  ari.sing  proxlmally  from  the  plexus  aorti- 
eus,  and  ending  distally  in  the  bilateral  pelvie  brain. 

logic  physiology,  disordered  function,  but  frequently  no  pathologic 
anatomy  can  be  detected.  At  menstruation  the  blood  volume  in  the 
tractus  intestinalis  rapidly  increases,  blood  pressure  is  raised,  compress- 
ing or  traumatizing  the  nerves  to  a  degree.  Limited  hematoma  may 
occur  in  the  endometrium,  congestion  is  intense,  inciting  vigorous  and 


154  ORIGINAL  AKTlCLtS. 

disordered  peristalisis  of  the  uterus  and  oviducts.  In  short  the  trauma 
oi"  shock  of  menstruation  of  the  genital  tract  irritates  it  into  a  state  of 
pain.  It  is  a  state  of  pathologic  physiology,  disordered  function,  but 
no  pathologic  anatomy  may  be  palpable.     The  affliction  is  functional. 

(d)  The  student  finally  asks  the  patient:  How  many  days  does 
the  monthly  flow  continue?  The  answer  may  be,  two  to  eight  days. 
Two  days  is  deficient  (amenorrhea  or  oligemia)  ;  four  days  is  normal, 
eight  days  is  excessive  (menorrhagia).  I  have  examined  scores  of 
gynecologic  patients  with  over  a  week's  flow,  menorrhagia,  but  in  many 
of  them  no  pathologic  anatomy  or  change  of  structure  could  be  detected. 
It  is  typical  pathologic  physiology,  disordered  unusual  function.  The 
subject  is  like  a  watch  with  an  excessively  powerful  mainspring.  The 
watch  has  no  detectable  pathologic  anatomy,  no  change  of  structure. 
The  mainspring,  the  automatic  ganglia,  is  excessively  active.  The 
organ  is  working  excessively,  the  watch  is  gaining  time.  The  auto- 
matic ganglia  are  prematurely  powerful,  the  watch  spring  is  too  strong. 
Menorrhagia  in  many  subjects  is  typical  pathologicl  physiology.  The 
pathologic  anatomy,  if  it  exists,  is  too  subtle  for  us  to  detect.  The 
adult  life  of  the  tractus  genitalis  presents  an  excellent  field  for  study 
and  teaching  in  pathologic  physiology.  Its  several  periodic  functions, 
its  changing  volume  of  circulation,  the  limited  life  of  its  parenchyma- 
tous cells  and  its  automatic  menstrual  ganglia  afford  a  useful  field  for 
study  and  development  of  pathologic  physiology. 

(7)  Gestation  presents  many  phases  of  pathologic  physiology. 
There  is  the  typical  pathologic  physiology,  namely,  emesis,  albuminuria, 
hypertrophy  of  left  ventricle,  pigmentation,  capricious  appetite,  consti- 
pation, increase  of  panicular  adiposus,  the  peculiar  gait,  venous  engorge- 
ment (edema),  excessive  glandular  secretion,  osteomalacia.  The  vom- 
iting of  pregnancy  may  present  a  vast  zone  from  slight  regurgitation 
of  food  to  profound  anemia  due  to  limited  nourishment — where  path- 
ologic physiology  alone  tells  the  tale.  The  normal  physiologic  nerve 
relations  between  the  tractus  genitalis  (uterus)  and  tractus  intestinalis 
(stomach)  have  become  disordered.  No  pathologic  anatomy  is  demon- 
strable. Constipation  (pathologic  physiology)  is  liable  to  arise  during 
gestation  because  the  normal  physiologic  blood  supply  of  the  tractus 
intestinalis  is  robbed  to  supply  the  increasing  demand  of  the  gestating 
genital  tract.  The  albuminuria  of  pregnancy  is  doubtless  partially  due 
to  pressure  of  the  expanding  uterus  on  the  ureters  and  veins  obstruct- 
ing venous  and  urinal  flow.  The  normal  physiologic  relations  between 
the  tractus  urinaria  and  the  gestating  tractus  genitalis  has  become  pro- 
jected into  the  field  of  pathologic  physiology.  Pathologic  anatomy  is 
not  in  evidence  except  as  ureteral  dilatation — a  secondary  matter.  A 
comprehensive  view  of  pathologic  physiology  aids  in  diagnosis  and 
treatment.  It  will  impress  the  practitioners  with  the  utility  of  visceral 
drainage,  the  administration  of  ample  fluids  at  regular  intervals  to 
relieve  the  system  of  waste-laden  blood — irritating  substances.  Path- 
ologic physiology  teaches  us  to  restore  function  and  frequently  patho- 
logic anatomy  will  take  care  of  itself. 


TRACTUS  GENITALIS.  166 

TREATMENT   OF    PATHOLOGIC    PHYSIOLOGY  OF  THE  TRACTUS 

GENITALIS. 

Since  pathologic  physiology  is  the  zone  between  physiology  and 
pathologic  anatomy,  it  should  be  amenable  to  treatment.  A  diagnosis 
by  exclusion  should  be  made.  It  must  be  remembered  that  in  the 
physiology  the  entire  six  abdominal  visceral  tracts  are  balanced  har- 
monious, functionating  without  friction — no  reflexes  dashing  hither  and 
yon  disturbing  the  exquisitively  poised  visceral  physiology.  In  the 
treatment  of  pathologic  physiology  of  the  tractus  genitalis  it  should  be 
remembered  that  the  genitals  are  not  vital  for  life,  but  that  the  richly 
nerve-supplied  genitals  dominate  the  mental  and  physical  existence  of 
woman.  In  the  treatment  of  pathologic  physiology  there  are  the  sub- 
jects of  periodic  hyperemia,  congestion,  hemorrhages,  excessive  glan- 
dular secretions,  disturbed  sensation  (hyperesthesia).  First  and  fore- 
most in  the  treatment  of  pathologic  physiology  of  the  tractus  genitalis, 
the  adjacent  visceral  tracts  must  be  regulated  to  normal  states  as  to 
drainage  but  especially  as  to  the  physiologic  condition  of  blood.  Fre- 
quently by  producing  daily  evacuation  of  the  digestive  tract  and 
increasing  the  renal  secretion  by  ample  fluids  the  pathologic  physiology 
of  the  genital  tract  improves.  The  genitals  should  be  examined  for 
adherent  prepuce,  pudendal  fissure,  pruritus  pudendae,  or  other  point  of 
irritation.  The  other  five  abdominal  visceral  tracts  (urinarius,  intesti- 
nalis,  vascularis,  lymphaticus,  nervosus)  should  be  examined  for 
points  of  visceral  irritation.  The  frequent  splanchnoptotic  condition 
must  be  studied  and  remedied. 

/.     VISCERAL  DRAINAGE. 

For  many  years  I  have  applied  a  treatment  to  such  subjects  which 
I  term  visceral  drainage.  Visceral  drainage  signifies  that  visceral  tracts 
are  placed  at  maximum  elimination.  The  waste  product  of  food  and 
tissue  are  vigorously  sewered  before  new  ones  are  imposed.  The  most 
important  principle  in  internal  medication  is  ample  drainage  for  every 
visceral  tract.  The  residual  products  of  food  and  tissue  should  have  a 
maximum  drainage  in  health.  I  suggest  that  ample  visceral  drainage 
may  be  executed  by  means  of:     (A)  Fluids;  (B)  Food. 

(A)   Visceral  Drainage  by  Fluids. 

The  most  effective  diuretic  is  water.  One  of  the  best  laxatives  is 
H2O.  One  of  the  best  stimulants  of  renal  epithelium  is  sodium 
chloride  (one-half  to  one-quarter  physiologic  salt  solution).  Hence  I 
administer  eight  ounces  of  half  normal  salt  solution  to  a  patient  six  times 
a  day,  two  hours  apart.  (Note. — Sodium  chloride  is  contraindicated  in 
parenchymatous  nephritis).  Forty-eight  ounces  of  half  normal  salt 
solution  daily  efficiently  increases  the  drain  of  the  kidney.  It  main- 
tains in  mechanical  suspension  the  insoluble  uric  acid;  it  stimulates 
other  matters;  it  aids  the  sodium,  potassium,  or  ammonium  salts  to 
form  combination  with  the  uric  acid,  producing  soluble  urates.     The 


156  ORIGINAL  ARTICLES. 

half  normal  salt  solution  effectively  stimulates  the  peristalsis  and 
epithelium  of  the  tractus  intestinalis  inducing  secretions  which  liquify 
feces,  preventing  constipation. 

(B)  Visceral  Drainage  by  Foods. 

The  great  functions  of  the  visceral  tract — peristalsis,  absorption, 
secretion,  sensation — are  produced  and  maintained  by  fluids  and  foods. 
To  drain  the  tractus  genitalis  and  adjacent  visceral  tracts  which  should 
be  excited  to  peristalsis,  foods  which  leave  an  indigestible  residue 
only  are  appropriate.  All  visceral  tracts  must  be  stimulated  to  maxi- 
mum peristalsis,  secretion,  and  absorption  in  order  to  aid  that  of  the 
tractus  genitalis.  Rational  foods  must  contain  appropriate  salts  whose 
bases  may  form  combinations  which  are  soluble,  as  sodium,  potassium, 
and  ammonium  combined  with  uric  acid  and  urates  to  form  soluble 
urates.  The  proper  foods  are  cereals,  vegetables,  albuminates  (milk, 
eggs),  mixed  f(X)ds.  Meats  should  be  limited  as  they  enhance  excessive 
uric  acid  formation.  In  order  to  stimulate  the  epithelium  (sensation) 
of  the  digestive  and  urinary  tract  with  consequent  increase  of  peris- 
talsis, absorption  and  secretion  in  both  I  used  S  part  or  multiple  of  an 
alkaline  tablet  of  the  following  composition:  Cascara  sagrada  (1-40 
grain),  aloes  (  1-3  grain),  sodium  carbonate  ( i  grain),  potassium  car- 
bonate ( 1-3  grain),  magnesium  sulphate  (2  grains).  The  tablet  is  used 
as  follows:  One-sixth  to  one  tablet  (or  more  as  required  to  move  the 
bowels  freely,  once  daily)  is  placed  on  the  tongue  before  meals  and  fol- 
lowed by  eight  ounces  of  water  (better  hot).  Also  10  a.  m  to  3  p.  m., 
and  at  bedtime  one-sixth  to  one  tablet  is  placed  on  the  tongue  and  fol- 
lowed by  a  glassful  of  any  fluid.  In  the  combined  treatment  one-third 
of  the  scxlium  chloride  tablet  (containing  eleven  grains)  and  one-sixth 
to  three  alkaline  tablets  are  placed  on  the  tongue  together  every  two 
hours,  followed  by  a  glass  of  fluid.  The  eight  ounces  of  fluid  may  be 
milk,  buttermilk,  eggnog — nourishing  fluid.  This  method  of  treatment 
furnishes  alkaline  bases  (sodium,  potassium  and  ammonium)  to  com- 
bine with  the  free  uric  acid  in  the  urine,  producing  perfectly  soluble 
alkaline  urates  and  materially  diminishing  the  insoluble  free  uric  acid  in 
the  urine.  Besides  the  alkaline  laxative  tablet  increases  the  peristalsis, 
absorption  and  secretion  of  the  intestinal  tract,  stimulating  the  sensation 
of  the  mucosa — aiding  evacuation.  I  have  termed  the  sodium  chloride 
and  alkaline  laxative  method  the  visceral  drainage  treatment.  The 
alkaline  and  sodium  chloride  tablets  take  place  of  the  so-called  mineral 
waters.  I  continue  this  dietetic  treatment  for  weeks,  months,  and  the 
results  are  remarkably  successful,  especially  in  the  pathologic  physi- 
ology of  the  visceral  tracts.  The  urine  becomes  clarified  like  spring 
water  and  increases  in  quantity.  The  tractus  intestinalis  becomes  freely 
evacuated,  regularly,  daily.  The  caliber  of  the  tractus  vascularis 
becomes  a  powerful  fluid  volume  to  carry  oxygen  and  food  to  tissue, 
while  the  effete  matter  and  waste  products  are  rapidly  swept  into  the 
.sewer  channels.     The  blood  is  relieved  of  waste-laden  and  irritating 


TRACTUS  GENITALIS.  167 

material.  The  tractus  cutis  eliminates  freely  and  the  skin  becomes 
normal.  The  appetite  increases.  The  sleep  improves.  The  patient 
becomes  hopeful,  natural  energy  returns.  The  sewers  of  the  body  are 
drained  and  flushed  to  a  maximum. 

IL— VAGINA!.  DOUCHE. 

(i)  The  kind  of  instrument  to  employ  is  a  fountain  syringe  of 
fourteen-quart  capacity.  The  simplest  and  most  economic  vaginal 
syringe  is  a  fourteen-quart  wooden  pail,  the  kind  generally  used  in 
transporting  candy  or  tobacco. 

(2)  The  location  of  the  syringe  should  be  four  feet  above  the 
patient. 

(3)  The  quantity  of  fluid  administered  in  the  beginning  should  be 
two  quarts  for  patients  unaccustomed  to  its  use  and  four  quarts  to  those 
accustomed  to  its  use.  The  quantity  should  be  increased  a  pint  at  each 
administration  to  fourteen  quarts. 

(4)  The  temperature  of  the  douche  should  be  105°  in  the  beginning 
and  increased  one  degree  at  each  administration  until  it  is  as  hot  as  it 
can  be  borne  (115°  to  120*"). 

(5)  The  duration  of  the  douche  should  be  ten  minutes  for  each 
gallon. 

(6)  The  time  to  administer  the  douche  is  in  the  evening  immedi- 
ately before  retiring  and  in  the  morning  (after  which  the  patient  should 
lie  horizontally  for  forty-five  minutes). 

(7)  The  position  of  the  patient  should  be  lying  on  the  back. 

(8)  As  to  method  of  administering  the  douche  the  patient  should  lie 
on  a  sufiiciently  inclined  plane  to  allow  the  returning  fluid  to  drain  into 
a  vessel  (pail,  pan).  The  ironing  board,  wash-tub  or  board  resting  on 
the  bath-tub  serves  convenient  purposes.  The  douche  should  not  be 
administered  in  the  bed  (unless  ordered),  standing  or  sitting  postures 
or  on  the  water-closet. 

(9)  As  to  ingredients  a  handful  of  sodium  chloride  and  a  teaspoon- 
ful  of  alum  should  be  added  to  each  gallon,  the  sodium  chloride  to 
dissolve  the  mucus  and  pus,  to  act  as  an  antiseptic  and  to  prevent 
reaction,  while  the  alum  is  to  astringe,  check  waste  secretions  and 
harden  tissue. 

(  10)  The  vaginal  tube  employed  in  administering  the  douche  should 
be  sterilized,  boiled,  and  every  patient  should  possess  her  own  vaginal 
tube.  The  most  useful  vaginal  tube  is  the  largest  that  can  be  con- 
veniently introduced  or  the  one  that  distends  the  vaginal  forces  so  that 
the  hot  fluids  will  bathe  the  greatest  surface  area  of  the  proximal  or 
upper  end  of  the  vagina. 

(11)  The  utility  of  a  vaginal  douche  is:  (a)  It  contracts  tissue 
(muscle,  elastic  and  connective)  ;  (b)  it  contracts  vessels  (lym- 
phatics, veins  and  arteries);  (c)  it  absorbs  exudates;  (d)  it  checks 
secretion:  (e)  it  stimulates;  (f)  it  relieves  pain:  (g)  it  cleanses;  (h) 


158  ORIGINAL  ARTICLES. 

it  checks  hemorrhage;  (i)  it  curtails  inflammation;  (j)  it  drains  the 
tractus  genitalis.  The  utility  of  the  vaginal  douche  depends  on  the 
quantity  of  fluid,  the  degree  of  temperature,  its  composition,  the 
position  of  the  patient  during  administration,  and  on  systematic  methods 
of  use. 

(12)  Disinfectants  in  a  vaginal  douche  are  secondary  in  value  to 
solvents  of  mucus,  pus,  leucocytes. 

(13)  The  objects  to  accomplish  by  a  douche  are:  (a)  The  dissolv- 
ing of  the  elements  in  the  discharge,  as  mucus,  pus,  and  leucocytes ;  (b) 
the  mechanical  removal  of  morbid  secretions,  accumulations  and  foreign 
bodies;  (c)  antisepsis;  (d)  diagnosis  (and  it  includes  number  11). 

( 14)  The  requirements  of  a  douche ;  (a)  It  should  be  nonirritating ; 
(b)  it  should  be  a  clear  solution;  (c)  it  should  possess  solvent  powers 
of  pus,  and  especially  mucus;  (d)  it  should  be  continued  for  months; 
(e)  omit  the  douche  for  four  days  during  menstruation. 

(15)  A  vaginal  douche,  administered  according  to  the  above  direc- 
tions, will  prove  to  be  of  therapeutic  value,  in  the  treatment  of  pelvic 
disease,  a  prophylactic  agent,  and  a  comfort  to  the  patient. 

( 16)  The  vaginal  douche  is  contraindicated  in  subjects  with  oviduc- 
tal  gestation  or  acute  pyosalpinx  as  it  it  liable  to  induce  rupture  of  the 
oviductal  wall,  abortion  or  leakage  of  pus  through  the  abdominal 
oviductal  sphincter. 

Ill,— VAGINAL   I^AMPOiV. 

( 1 )  The  composition  of  the  vaginal  tampon  consists  of  a  roll  of 
medicated  cotton  (hen-egg  size),  tied  to  a  twelve-inch  string,  placed 
in  a  solution  of  sixteen  ounces  of  glycerine  and  two  ounces  of  boracic 
acid. 

(2)  The  duration  of  preparation  of  vaginal  tampon  should  be  to  lie 
in  the  boroglyceride  solution  forty-eight  hours  before  using. 

(3)  The  utility  of  the  vaginal  tampon  is  :  (a)  It  is  hygroscopic ;  (b) 
it  serves  as  a  mechanical  support;  (c)  it  contracts  tissue  (muscle, 
elastic,  connective)  ;  (d)  it  contracts  vessels  (lymhatics,  veins  and 
arteries)  ;  (e)  it  hastens  absorption  of  exudates;  (f)  it  checks  secre- 
tions; (g)  it  stimulates;  (h)  it  curtails  inflammation;  (i)  it  drains  the 
pelvic  organs;  (j)  it  cleanses;  (k)  it  dissolves  mucus,  pas,  and  leuco- 
cytes. The  utility  of  a  vaginal  tampon  depends  on  its  composition,  the 
quantity  employed,  the  duration  of  its  application,  and  on  systematic 
method  of  use. 

(5)  The  methods  of  introduction  consists  in  placing  three  to  five 
vaginal  tampons  (with,  or  better,  without  a  speculum)  in  the  vaginal 
fornices  in  the  direction  of  least  resistance. 

(5a)  Disinfectants  in  a  vaginal  tampon  is  secondary  to  its  other 
qualities,  especially  that  of  hygroscopy. 

(6)  The  object  to  accomplish  by  a  vaginal  tampon  is:  Maximum 
hygroscopy,  dissolving  the  elements  in  the  discharge,  as  mucus,  pus. 


TRACTUS  GENITALIS.  169 

leucocytes,  the  mechanical  removal  of  morbid  secretions,  accumulation 
and  foreign  bodies,  diagonis,  and  mechanical  support. 

(7)  The  diagnosis  is  aided  by  the  use  of  a  tampon  by  collecting 
and  preserving  the  uterine  discharge  (as  pus,  blood,  debris). 

(8)  The  requirements  of  a  vaginal  tampon  are:  (a)  It  should  be 
nonirritating ;  (b)  it  should  possess  hygroscopic  power;  (c)  it  should 
be  a  solvent  of  discharges  (mucous,  pus,  leucocytes,  blood) ;  (d)  it 
should  aid  in  the  dissolving  of  the  mechanical  removal  of  morbid  secre- 
tions, accumulations,  and  foreign  bodies;  (e)  it  should  be  aseptic  (not 
necessarily  antiseptic)  ;  (f)  it  should  not  indelibly  stain  the  clothing 
(this  is  objection  to  its  use  as,  for  example,  ichthyol)  ;  (g)  it  should 
be  reasonably  economic. 

(9)  The  frequency  of  application  of  the  boroglyceride  vaginal  tam- 
pons should  be  in  general,  twice  weekly,  more  frequent  employment 
may  cause  irritation. 

(10)  The  time  to  apply  the  tampon  is  at  night  during  maximum 
anatomic  and  physiologic  rest. 

(11)  The  duration  the  tampon  may  remain  usefully  in  position  is 
ten  to  twenty-four  hours. 

(12)  There  are  no  special  contraindications  to  the  application  of  the 
vaginal  tampon  (in  pelvic  disease). 

(13)  The  boroglyceride  vaginal  tampon  may  be  beneficially  applied 
in:  (a)  inflammatory  pelvic  disease  (vaginitis,  endometritis,  myome- 
tritis, endosalpingitis,  myosalpingiti3,  pelvic  peritonitis,  proctitis,  cys- 
titis) ;  (b)  sacropubic  hernia,  support  for  the  uterus,  cystocele  and 
rectocele)  ;  (c)  in  genital  ptosis  it  depletes  the  lymphatics  and  veins. 

(14)  A  vaginal  tampon  applied  according  to  the  above  directions 
will  prove  to  be  of  therapeutic  value  in  the  treatment  of  pelvic  disease, 
a  prophylactic  agent  and  a  comfort  to  the  patient. 

JV,—J/AB/TAT, 

The  value  of  fresh  air  was  never  realized  so  much  as  at  present. 
Fresh  cold  air  cures  pulmonary  and  other  tuberculosis.  The  success  of 
the  sanitarium  is  the  continued  use  of  fresh  (cold)  air.  The  subject 
should  sleep  with  fresh  cold  air  passing  through  an  open  window  space 
of  three  by  three  feet.  It  appears  to  be  demonstrated  that  cold  fresh 
air  is  more  beneficial  than  warm  fresh  air.  It  is  common  talk  among 
people  that  one  winter  in  the  mountain  is  worth  two  summers  for  the 
consumptive.  The  curative  and  beneficial  effect  of  cold  fresh  air  con- 
tinually, day  and  night,  for  the  family  must  be  preached  in  season  and 
out  of  season  by  physicians.  The  windows  should  be  open  all  night. 
Fresh  cold  air  is  one  of  the  best  therapeutic  agents  in  pathologic  physi- 
ology of  the  tractus  genitalis. 

Exercise  is  an  essential  for  health.  Muscles  exercise  a  dominating 
control  over  circulation  (blood  and  lymph).  The  abdominal  muscles 
influence  the  caliber  of  the  splanchnic  vessels.  They  exercise  an  essen- 
tial influence  over  the  peristalsis  secretion,  absorption  of  the  tractus 


160  ORIGINAL  ARTICLES. 

intestinalis,  urinarius  vasculoris  and  genitalis.  The  muscles  massage 
the  viscera,  enhancing  their  function  and  the  rate  of  circulation.  In  the 
uterus,  the  most  typical  example,  it  is  prominently  marked  how  the 
myometrium  controls  the  blood  currents  like  living  ligatures.  The 
habitat  that  furnishes  opportunity  for  abundant  fresh  air  and  ample 
exercise  is  the  one  that  affords  the  essential  chances  for  recovery  of 
pathologic  physiology  in  the  tractus  genitalis. 


SOME  MEDICAL  MISTAKES.* 
By  miles  F.  porter,  M.  D.,  Fort  Wayne.  Indiana. 

PROPRSSOR  OP   SURGBRY  IN  THB  INDIANA   MBOICAL  COLLBGB,    DBPARTMBNT  OF   MBDICINB  OP   PUKDUB 

UmVBBSITY. 

"To  err  is  human,  to  forgive  divine.'*  To  acknowledge  error  to 
our  brothers  that  they  may  avoid  erring  likewise,  is  manly.  The  man 
who  never  makes  a  mistake  has  not  yet  been  born.  Not  he  who  makes 
mistakes,  but  he  who  makes  mistakes  and  fails  to  profit  by  them  is  a 
dangerous  doctor.  Experience  teaches  very  largely  through  mistakes 
used  as  object  lessons.  Medical  meetings  might  be  more  profitable 
were  we  to  report  more  of  our  failures  and  fewer  of  our  successes. 
There  should  be,  in  the  interest  of  our  patients,  a  general  reciprocity  in 
the  profession  in  the  matter  of  mistakes  and  failures  as  well  as  in  the 
matter  of  successes.  When  such  reciprocity  prevails  professional 
advancement  will  be  more  rapid  than  it  is  now.  What  appears  to  me 
as  a  mistake  may  appear  to  another  more  capable  of  judging  than  I,  to 
be  altogether  good.  Let  us  therefore  talk  and  tell  of  the  mistakes  as 
they  appear  to  us,  frankly  and  fearlessly  but  with  tolerance,  having  in 
mind  Cromwell's  admonition  to  the  Scotch  Parliament,  "In  the  name 
of  God,  Gentlemen,  conceive  it  possible  that  you  may  be  mistaken." 
Nor  must  we  forget  that  the  methods  we  criticize  today  may  be  those 
we  adopt  tomorrow,  and  that  the  men  who  now  seem  well-nigh  impos- 
sible may,  as  we  learn  to  know  them  better,  rise  in  our  estimation  until 
in  the  end,  honesty  may  compel  us  to  say  of  them  as  does  Tommy 
Atkins  (^f  Gunga  Din, 

"Though  Tve  belted  you  and  flayed  you 
"hy  the  living  God  that  made  you 
You're  a  better  man  than  I  am,  Gunga  Din." 

Let  these  discussions  be  impersonal  when  they  may  be,  personal  if  they 
must  be,  always  without  malice,  conducted  with  candor  and  always 
between  ourselves.    Our  motto  in  this  matter  might  well  be,  "An  open 
field  and  a  fair  fight,"  not  with  a  view  towards  determining  "who  is  the- 
best  man,"  but  for  the  purpose  of  making  us  all  better  doctors. 

If  one  with  so  little  experience  as  I  in  pedagogy  might  be  permitted 
to  speak  on  the  subject,  I  would  like  to  refer  to  what  seems  to  me  a 
serious  error  in  the  method  of  teaching,  which  is  quite  prevalent  in 

♦Read  at  the  Detroit  meeting  of  the  Northern  Tri-State  Medical  Society. 


SOME  MEDICAL  MISTAKES.  161 

our  medical  schools.  Too  much  effort  is  made  to  cram  the  student  full 
of  facts  and  too  much  stress  is  laid  upon  the  necessity  of  his  acquiring 
them,  and  too  little  time  and  energy  is  spent  in  teaching  him  to  think, 
to  reason,  to  see  the  relationship  that  one  fact  holds  to  another,  to  the 
end  that  if  given  the  basic  principles,  he  may  himself  deduce  their 
practical  application.  Wisdom  rather  than  knowledge  should  be  the 
chief  aim  of  both  student  and  teacher. 

The  large  clinic,  as  a  teaching  medium,  is  very  largely  a  farce. 
Barring  the  good  that  the  student  gets  from  the  talk,  and  the  good 
which  a  very  few  who  are  close  to  the  patient  get  from  observation, 
the  large  clinic  serves  no  purpose  worthy  the  energy  and  expense 
entailed.  That  the  large  clinic  is  still  recognized  as  a  method  of  teach- 
ing is  due  to  two  facts ;  first,  the  general  tendency  to  revere  that  which 
is  old,  and  second,  it  is  a  good  advertising  medium  for  the  clinician, 
and  the  institution  under  tne  auspices  of  which  it  is  held.  We  must 
increase  the  number  of  the  clinics  and  decrease  the  size  of  the  classes. 

The  prevailing  tendency  of  most  students,  and  doctors  as  well,  is 
toward  that  which  is  practical,  hence  the  tendency  to  slight  the  funda- 
mental principles  and  take  up  the  so-called  practical  branches  before 
the  student  is  prepared  for  this  work.  This  tendency  might  be  men- 
tioned as  a  third  reason  why  the  large  clinic  still  flourishes.  Prac- 
titioners  and  teachers  should  strive  to  inculcate  the  student's  mind 
with  the  fact  that  a  thorough  mastery  of  the  principles  of  medicme  is 
necessary  before  one  is  capable  of  understanding  the  practical  branches. 

The  undergraduate  student  who  pursues  his  studies  with  a  view  of 
l)racticing  a  specialty  after  graduation  makes  a  grievous  error  and  the 
schools  who  encourage  this  kind  of  work  err  likewise.  To  make  a 
good  specialist  we  must  first  have  a  good  general  practitioner.  This 
entails  a  comprehensive  study  of  all  the  branches  as  indicated  in  the 
usual  four  years'  course  supplemented  by,  I  should  say,  at  least  five 
years  of  general  practice.  The  young  doctor  who  launches  at  once 
into  a  specialty  after  getting  his  degree,  may  be  a  very  good  specialist, 
comparatively,  but  like  the  man  who  enters  upon  the  study  of  medicine 
without  an  adequate  preliminary  education,  he  does  himself  an  injustice, 
because  he  cannot  in  this  way  do  the  best  of  which  he  is  capable. 

We  should  strive  also  to  impress  prospective  medical  students  with 
the  necessity  of  a  good  education  preparatory  to  entering  upon  their 
professional  studies.  One  who  takes  up  the  study  of  medicine  with  an 
untrained  mind  does  himself  an  injustice.  He  may  succeed  in  making 
of  himself  a  splendid  doctor,  but  he  cannot  achieve  that  success  which 
might  have  been  his  had  he  started  without  the  handicap  of  an  inefiicient 
preliminary  education.  Given  a  good  preliminary  education  and  a 
good  medical  education  supplemented  with  a  year's  hospital  training 
and  it  w-ould  seem  that  one  should  be  well  equipped  for  the  practice 
of  his  profession,  but  is  he?  Comparatively  speaking,  yes,  but  actually, 
no.  He  finds  that  hospital  methods  and  manners  are  not  applicable  in 
private  practice  and  the  changes  necessary  are  often  not  worked  out 


162  ORIGINAL  ARTICLES. 

under  long  months  and  sometimes  years  of  patient  and  oft-times  painful 
toil.  Because  this  is  true,  I  "am  not  at  all  sure  that  we  gained  much 
when  we  substituted  clinical  and  hospital  teaching  for  the  didactic 
lecture  and  the  apprenticeship.  A  year's  experience  w-ith  a  good  gen- 
eral practitioner  is  worth  more  to  the  recent  graduate  in  medicine  than 
is  a  year's  hospital  w'ork.  To  have  both  is  better,  but  if  he  can  have 
but  the  one,  then  I  would  advise  a  year's  practice  under  the  direction 
of  a  good  doctor  in  general  practice. 

Man  is  a  machine,  and  something  more,  he  is  a  sentient  being  and 
one  can  gain  but  a  very  incomplete  knowledge  of  him  by  studying  his 
parts  in  a  laboratory.  This  piecemeal  study  of  the  human  body  is 
valuable,  it  is  essential  in  a  medical  education,  but  it  is  by  no  means 
sufficient.  The  doctor  must  study  the  w^hole  live  man,  sick  and  sound, 
well-formed  and  deformed.  It  has  seemed  to  me  that  there  has  lately 
been  a  tendency  to  slight  the  study  of  the  patient  himself  for  a  study 
of  his  tissues  and  secretions.  The  value  of  blood  analyses,  urine 
analyses,  cryoscopy,  microscopic  and  bacteriologic  examinations,  has, 
it  seems  to  me,  been  overestimated  while  older  and  more  reliable 
methods  of  examination  have  been  undervalued.  I  would  not  be  mis- 
understood. Chemic,  microscopic  and  bacteriologic  examinations  are 
valuable  adjuncts  in  diagnosis,  and  we  should  avail  ourselves  of  their 
help,  but  they  are  seldom  as  dependable  as  are  the  older  methods,  such 
as  palpation,  percussion,  et  cetera. 

I  have  known  the  leucocyte  count  to  indicate  pus  in  an  appendix 
where  there  was  no  pus,  and  no  evidences  of  inflammation  save  upon 
microscopic  examination,  but  I  have  never  seen  rigidity  and  tenderness 
of  the  abdomen  without  peritonitis,  nor  peritonitis  without  tenderness 
and  rigidity.  I  have  seen  a  man  die  in  uremic  convulsions  within 
twelve  hours  after  a  quantitative  analyses  of  his  urine  showed  that  he 
was  excreting  a  normal  amount  of  urea  and  it  was  declared  that  he 
was  in  no  danger  from  uremia.  I  have  known  a  skiagraph  to  show 
an  ugly  deformity  in  fractures  when  both  the  functional  and  cosmetic 
results  were  perfect.  On  the  other  hand,  I  have  seen  skiagraphs  that 
showed  perfect  results  when  in  reality  there  was  great  deformity  and 
much  loss  of  function. 

The  microscope  as  an  aid  in  the  diagnosis  of  malignant  disease  is 
well-nigh  invaluable,  but  it  is  by  no  means  infallible.  I  have  known 
growths  pronojLinced  innocent  after  microscopic  examination  to  prove 
themselves  violently  malignant,  and  I  have  known  others  to  be  pro- 
nounced malignant  when  all  other  evidence  was  to  the  contrary.  It  is 
well  known  that  a  man  may  be  perfectly  well  and  yet  carry  either 
tubercle  bacilH,  the  Klebs-Loeffler  bacillus,  or  the  pneumococcus  in  the 
secretic^n  of  his  mouth  and  throat. 

Have  the  mo<lern  methods  of  analysis  of  the  stomach  contents 
resulted  in  earlier  diagnosis  in  gastric  cancer?  Answering  from  per- 
sonal experience,  I  should  say  no,  and  I  am  not  aw'are  that  my  experi- 
ence along  this  line  has  been  peculiar.  » 


SOME  MEDICAL  MISTAKES.  163 

The  natural  senses  unaided  save  by  means  used  to  make  otherwise 
inaccessible  parts  accessible,  such  as  anesthesia  specula,  et  cetera,  are 
the  most  reliable  diagnostic  means  known,  and  the  cultivation  of  these 
senses  for  this  use  remains  today  as  the  surest  and  best  way  to  the 
achievement  of  diagnostic  skill.  With  the  creation  of  instruments  of 
precision  and  the  development  of  laboratory  methods  has  grown  up  a 
tendency  to  neglect  the  study  of  the  patient  himself,  a  tendency  to  less 
careful  and  painstaking  observation  of  symptoms.  Just  here,  too,  let 
me  say  that  we  are  losing  the  art  of  expressing  ourselves  clearly  and 
elegantly.  Would  you  have  proof  that  we  are  less  accurate  observers 
than  our  fathers  in  medicine  and  that  we  express  ourselves  less  well, 
procure  Watson's  "Practice,''  Fothergill's  "Handbook  of  Treatment," 
and  compare  them  with  like  works  of  the  present  day.  To  be  sure,  we 
have  gained  much  but  we  have  lost  also  not  a  little.  My  contention 
is  that  we  may  continue  to  gain  just  as  rapidly  at  a  lesser  loss  than 
now  obtains. 

Measured  by  morbidity  and  mortality  the  costliest  error  and  the 
commonest  is  delay.  Practically  all  the  deaths  due  to  appendicitis  and 
strangulated  hernia,  and  more  than  half  of  those  due  to  tuberculosis 
and  cancer  might  be  prevented  by  prompt  diagnosis  and  treatment. 
Better  remove  a  dozen  healthy  appendices  than  to  allow  one  to  remain 
until  it  perforates,  but  there  need  be  no  necessity  for  doing  either. 
Taxis  in  strangulated  hernia  is  dangerous  and  should  be  abandoned. 
An  early  operation  cures  the  hernia  permanently  and  practically  with- 
out risk.  Practically  all  tumors  should  be  removed  as  soon  as  their 
existence  is  known.  This  will  mean  the  removal  of  many  benign 
tumors  to  be  sure,  but  it  wall  also  mean  the  removal  of  malignant  tumors 
in  time  to  obtain  a  permanent  cure.  In  this  connection,  too,  it  should 
be  remembered  that  nonmalignant  tumors  frequently  become  malignant, 
so  that  in  the  end  the  advice  to  remove  all  tumors  early  will,  if  fol- 
lowed, result  in  a  great  decrease  in  the  mortality  and  morbidity  due  to 
neoplasms. 

Prostatism,  that  bane  of  old  men,  will  have  largely  lost  its  terrors 
when  timely  prostatectomy  comes  to  be  recognized,  as  it  should  be,  as 
the  only  correct  treatment  for  this  condition. 

There  is  one  more  mistake  quite  prevalent  to  which  I  want  to  refer, 
namely,  unnecessary  dressing  and  meddling  with  wounds.  I  refer  to 
the  frequent  Washings  of  pus  cavities,  the  probing  of  sinuses,  the  cut- 
ting away  of  sloughs,  the  curetting  of  recent  wounds  to  remove  foreign 
matter,  the  removal  of  bone  fragments,  injured  skin  and  muscles,  and 
the  frequent  removal  of  dressings  for  the  purpose  of  inspecting  a 
wound.  In  certain  cases  these  measures  are  not  only  permissible  but 
demanded,  of  course,  but  that  they  are  instituted  all  too  often  for  the 
comfort  and  welfare  of  the  patient  I  am  convinced.  To  wash  pus 
cavities  is  usually  worse  than  useless,  loose  bone  fragments  often 
become  fixed  and  serve  a  useful  purpose,  to  cut  a  slough  free  is  to 
open  a  new  avenue  for  infection,  skin  and  other  tissues  that  seem 


164  ORIGINAL  ARTICLES. 

injured  beyond  repair  may  live,  curettage  of  recent  wounds  adds  insult 
to  injury  and  usually  is  harmful  rather  than  beneficial,  dressings  prop- 
erly applied  should  not  be  changed  until  the  wound  is  either  healed  or 
covered  with  granulations  unless  the  conditions  demand  it. 

For  all  doctors  to  do  all  things  necessary  as  soon  as  the  necessity 
.  arose,  and  avoid  doing  all  things  unnecessary  and  harmful  would  be 
to  achieve  perfection.     This  is  impossible,  hence  it  will  ever  remain 
onr  blessed  privilege  to  strive. 

207  West  Wayne  Street. 


TONSILLITIS  AND  ITS  COMPLICATIONS.* 
By  CHARLES  F.  KUHN,  M.  D.,  Detroit.  Michigan. 

LBCrUKSR  ON   PHYSIOLOGY   IN  THE   MICHIGAN  COLLBGB  OF   MBDICINR  AND  SURGERY. 

Much  has  been  said  of  late  concerning  the  analogy  between  ton- 
sillitis and  acute  inflammatory  rheumatism.  It  has  recently  fallen  to 
my  lot  to  treat  a  number  of  cases  in  which  the  sequalae  have  been  dis- 
astrous, and  I  have  been  lead  to  regard  tonsillitis  as  one'  of  the  most 
serious  diseases  we  have  to  treat,  and  one  which,  if  not  properly  treated, 
leaves  the  patient  in  a  debilitated  state,  susceptible  to  any  and  all 
infections. 

I  believe  the  tonsil  to  be  an  abnormal  gland  or  adenoid,  and  in  exam- 
ining several  hundred  throats  found  an  entire  absence  of  the  faucial 
tonsils  in  over  half  the  patients,  and  only  a  rudimentary  tonsil  in  many 
others.  The  existence  of  full-sized  tonsils  such  as  are  described  in 
works  on  anatomy  is  relatively  rare,  the  largest  being  found  in  children 
and  young  adults.  Persons  with  large  tonsils  are  invariably  afflicted 
with  "catarrh,"  since  being  mouth-breathers  in  consequence  of  the  small 
nasopharynx,  various  microorganisms  necessarily  lodge  in  the  crypts 
of  the  tonsils.  The  tendency  of  the  profession  and  laity  to  regard  ton- 
sillitis lightly,  allowing  the  patient  to  go  outdoors,  attend  to  business, 
work  hard,  or,  if  a  child,  to  go  to  school,  is  responsible  for  many  dam- 
aged hearts,  endocarditis,  hypertrophy  of  the  heart,  trachycardia,  otitis 
media,  deafness,  pleuritis,  mostoiditis,  inflammatory  rheumatism, 
anemia,  conjunctivitis  and  neurosis. 

The  following  cases  occurring  in  my  practice,  and  taken  from  my 
clinical  records,  convince  me  of  the  truth  of  the  assertions  made : 

Case  I. — A  young  man,  nineteen  years  of  age,  machinist,  previous 
health  good,  weight  one  hundred  forty  pounds,  habits  of  life  excellent, 
came  to  my  ofiice,  November  5,  1904,  suffering  with  sore  throat  and 
complaining  of  feeling  sore  all  over.  Examination  showed  follicular 
tonsillitis.  Temperature  101°,  pulse  90;  urinalysis  showed  specific 
gravity  T020,  reaction  acid,  and  slight  amount  of  albumin.  He  was 
told  to  return  home  and  remain  quiet  until  well,  a  diet  consisting  of 
milk,  broths,  and  toast  being  ordered.     Medicinal  treatment  embraced 

♦Read  before  the  Detroit  meeting  of  the  Northern  Tri- State  Medical 
Association. 


TONSILLITIS  AND  ITS  COMPLICAPIONS.  165 

fifteen  grains  of  salicylate  of  soda  with  five  minims  nux  vomica  in  elixir 
of  pepsin,  and  a  glass  of  water  every  three  hours,  together  with  a  gargle 
containing  twenty-five  per  cent  of  hydrogen  peroxide,  four  times  a  day. 
The  bowels  were  moved  with  sulphate  of  magnesia.  On  the  third  day 
this  patient  went  to  work  feeling  much  better,  but  after  laboring  several 
hours  became  weak,  and  by  noon  had  severe  pains  in  the  wrists.  He 
managed  to  work  all  day,  and  consulted  me  in  the  evening.  Examina- 
tion revealed  a  temperature  of  102°,  pulse  100,  full  and  bounding; 
wrists  swollen,  red  and  painful  to  the  touch.  The  heart  and  chest 
sounds  were  normal.  Patient  was  advised  to  repair  to  bed  and  remain 
there  until  well.  I  could  not  keep  him  in  bed,  however,  as  he  claimed 
he  felt  better  when  about.  An  erythematous  eruption  appeared  over 
his  body,  and  the  joint  symptoms  followed  the  usual  course,  attacking 
nearly  all  the  joints  from  time  to  time.  Endocarditis  and  hypertrophy 
followed,  and,  despite  all  that  was  done,  he  died  on  the  sixtieth  day. 

Case  II. — An  unmarried  lady,  twenty  years  old,  domestic,  family 
history  good,  previous  health  and  habits  good,  consulted  me  complain- 
ing of  sore  throat  and  pain  in  all  the  joints.  Examination  revealed 
tonsils  enlarged,  and  covered  with  a  follicular  exudate.  Temperature 
100°,  pulse  90;  chest  and  heart  sounds  normal.  She  was  told  to  go 
home  and  retire  to  bed  and  not  get  up  until  well.  A  diet  of  milk  and 
gruel  was  prescribed.  Medicinal  treatment  contemplated  salicylate  of 
soda  and  alkalies  internally,  with  a  gargle  locally.  Patient  continued 
her  work  for  two  days,  when  I  called  and  found  her  in  bed,  suffering 
intense  pain  in  her  left  knee-joint.  No  other  joints  were  involved. 
She  was  taken  to  a  hospital,  where  every  attention  was  given  her.  An 
ice-bag  was  placed  over  the  heart,  and  medication  was  given  according 
to  symptoms.  Consultation  was  held  several  times,  and  the  prognosis 
was  considered  favorable.  The  pain  and  swelling  continued  in  the  left 
knee-joint  and  endocarditis  developed  at  the  end  of  the  first  week,  death 
occurring  on  the  fourteenth  day. 

Case  III. — A  boy,  seventeen  years  old,  laborer,  appeared  at  my  office 
with  an  ordinary  follicular  tonsillitis.  He  had  been  sick  for  four  days. 
Temperature  101°,  pulse  100;  heart  and  chest  normal;  urine  contained 
albumin.  I  saw  him  at  his  home  again  the  next  day  and  found  him 
in  great  pain;  temperature  104°,  pulse  no;  dyspnea,  coated  tongue, 
diarrhea,  and  cold  perspiration.  Pain  was  referred  to  limbs  and  heart. 
An  ice-bag  was  applied  over  the  precordia;  one-fortieth  grain  of  sul- 
phate of  strychnine  was  given  per  orem,  three  times  a  day,  with  infusion 
of  digitalis,  and  twenty  cubic  centimeters  of  antistreptococcic  serum 
were  injected  daily.  I  saw  him  again  at  night  and  found  his  left  knee- 
joint  enormously  swollen  and  inflamed.  Patient  was  seen  in  consulta- 
tion by  several  physicians.  The  endocarditis  and  swelling  of  the  left 
limb  continued  until  death,  which  occurred  on  the  sixth  day. 

Case  IV. — A  married  woman,  twenty-four  years  old,  housewife.  I 
was  called  to  her  home  to  attend  her  in  confinement.  Patient  had 
always  enjoyed  good  health.     She  was  in  labor  about  twenty  hours, 


166  ORIGINAL  ARTICLES. 

and  I  delivered  her  with  instruments.  The  perineum  was  lacerated 
and  I  repaired  this  damage  at  .the  time.  The  usual  asepsis  was  observed 
preceding  and  during  the  puerperium.  On  the  fourth  day  the  nurse 
advised  me  that  the  patient  was  restless  and  had  some  fever.  Exami- 
nation revealed  a  temperature  of  102'',  pulse  no,  respiration  24. 
Vaginal  examination  showed  a  membranous  exudate  on  vulva  and 
cervix.  This  was  treated  locally  and  twenty  cubic  centimeters  of  anti- 
streptococcic serum  injected.  Patient  was  examined  at  about  10  o'clock 
that  night  and  local  treatment  applied.  I  washed  my  hands  in  a  lysol 
solution  as  on  other  occasions  and  went  home.  About  i  o'clock  I 
awoke  with  a  pain  in  my  right  index  finger.  I  could  not  sleep  so  I 
arose  and  found  on  examination  a  vesicle  on  the  palmar  aspect  of  the 
finger  near  the  tip.  I  had  a  rigor  and  a  very  restless  feeling;  sore  all 
over  my  body.  By  morning  I  had  a  typical  tonsillitis  and  infected 
finger.  I  was  quite  sick  for  three  days,  two  other  fingers  becoming 
infected,  first  with  a  vesicle,  and  then  a  pustule,  which  eventually 
healed.  No  culture  was  taken.  I  have  not  been  able  to  decide  whether 
I  infected  the  patient,  or  whether  she  infected  me.  She  recovered  in 
about  one  week. 

Case  V, — A  man,  twenty-two  years  old,  bank  clerk,  called  at  my 
ofiice  suffering  from  a  slight  attack  of  tonsillitis.  The  usual  remedies 
were  prescribed,  and  the  patient  advised  to  stay  at  home  and  keep 
perfectly  quiet.  He  told  me  the  next  morning  that  he  felt  much  bet- 
ter, and  that  as  business  was  urgent  at  the  bank,  he  thought  he  would 
return  to  work.  I  did  not  hear  from  him  for  several  days,  when  he 
came  to  my  office  complaining  of  a  pain  in  his  head.  Examination 
showed  a  normal  temperature,  chest  and  heart.  I  prescribed  three 
grains  of  the  sulphate  of  quinine  and  one-fourth  grain  of  the  sulphate 
of  codeine,  to  be  taken  every  three  hours.  I  also  admonished  him  to 
remain  quiet.  The  next  day  he  had  temperature  and  severe  pain  in 
the  he^d  and  ear.  I  suspected  otitis  media  and  ordered  hot  dry  heat 
to  the  ear.  Pain  became  severe  and  after  examination  I  performed 
peracentesis  of  the  drum,  which  afforded  no  relief.  Pressure  over  the 
antrum  and  tip  of  the  mastoid  caused  great  pain,  and  mastoiditis  was 
diagnosed,  for  the  relief  of  which  an  operation  was  performed. 

Case  VI. — A  school  girl,  sixteen  years  old.  Patient  had  large  ser- 
rated tonsils,  was  anemic,  and  suffered  with  frequent  headaches.  I 
diagnosed  neuralgia  and  suppurative  tonsillitis.  Tonsillectomy  was 
performed  August  7,  1904.  Her  general  health  improved  gradually 
and  she  has  been  free  from  throat  trouble,  headache  and  neuralgia 
since. 

Case  VII. — A  school  girl,  fifteen  years  old.  Patient  had  very  large 
tonsils  with  frequent  attacks  of  follicular  tonsillitis.  She  always  com- 
plained of  severe  earache  during  these  attacks,  and  suffered  wnth  head- 
ache and  shortness  of  breath  on  exertion.  I  advised  removal  of  tonsils, 
but  her  parents  objected.     She  is  now  seventeen  years  old  and  is  nearly 


TONSILLITIS  AND  ITS  COMPLICATIONS.  167 

deaf  in  her  left  ear.  She  also  has  tachycardia,  the  pulse  rate  being  140 
to  150.  There  is  a  slight  hypertrophy,  but  no  murmur  or  exophthalmic 
goiter.  An  interesting  feature  in  this  case  is  the  family  history.  Her 
father  and  mother  are  healthy.  The  family  consists  of  four  girls  and 
three  boys.  These  children  all  had  very  large  tonsils,  were  mouth 
breathers,  had  nasal  catarrh  and  were  sick  a  great  deal.  The  oldest 
girl,  aged  nineteen,  is  anemic  and  subject  to  hysteroepileptic  attacks. 
The  younger  ones  had  frequent  attacks  of  sore  throat  and  spasms. 
Four  years  ago  I  removed  the  tonsils  of  the  six-year  old  girl  and 
she  has  been  in  perfect  health  since. 

Case  VIII. — A  man,  age  twenty-eight,  machinist.  Patient  has  suf- 
fered with  numerous  attacks  of  follicular  tonsillitis.  His  tonsils  are 
hypertrophied  and  flabby.  Two  years  ago,  after  an  attack,  he  com- 
])lained  of  tinnitus  aurium,  from  which  he  is  a  constant  sufferer. 

From  the  above  cases  and  others  I  am  convinced  that  infection 
takes  place  through  the  tonsils,  and  that  the  follicles  and  crypts  are 
the  receptacles  for  the  streptococcus,  staphylococcus,  Klebs-Loeffler, 
tubercle  bacillus  and  other  forms  of  microorganisms.  Upon  exami- 
nation we  frequently  find  the  tonsil  diseased  with  sinuses  leading  into 
little  pockets  of  pus.  I  have  examined  a  number  of  patients  suffering 
with  endocarditis,  hypertrophy  of  heart,  pleuritis  deafness  and  rheuma- 
tism, and  giving  history  of  perfect  health  before  an  attack  of  sore 
throat,  for  which  they  did  nothing,  or  continued  to  work  while  taking 
medicine.  I  believe  the  toxins  are  disseminated  through  the  lymphatics 
and  blood-vessels,  as  the  cervical  and  inguinal  lymphatics  are  tender 
and  enlarged,  and  arteritis,  phlebitis,  and  embolism  occurs  in  the  blood- 
vessels. Patients  suffering  with  tonsillitis  should  be  warned  of  the 
danger  of  going  out  too  soon.  Absolute  rest  is  most  essential  and  the 
treatment  should  be  thorough.  The  tonsils  should  be  treated  locally 
with  a  gargle  of  acetezone,  normal  saline  solution,  or  one  of  the  alkaline 
solutions  on  the  market.  Internal  medication  as  indicated,  and  I  have 
a  preference  for  salicylate  of  soda.  Existing  anemia  should  not  be 
overlooked.  The  tincture  of  chloride  of  iron  in  large  doses  has  a  good 
effect.  The  heart,  lungs,  pleura,  intestinal  canal  and  kidneys  should 
be  carefully  watched.  The  diet  should  consist  of  milk,  cereals  and 
vegetables,  meat,  coffee,  tea,  or  alcohol  l)eing  prohibited.  Troublesome 
and  enlarged  tonsils  should  be  removed,  preferably  with  a  snare,  as  this 
prevents  hemorrhage.  If  only  a  small  piece  is  extirpated,  allowing 
drainage,  good  results  follow  in  cases  where  the  tonsils  cannot  be 
enucleated.  Cauterization  causes  scar-tissue  formation  which  is  pain- 
ful and  does  not  give  satisfactory  results. 

That  tonsillitis  is  a  local  manifestation  of  a  general  infection,  having 
a  selective  tendency  to  attack  all  the  serous  meml)ranes,  lymphatics  and 
blood-vessels  of  the  body,  I  am  certain.  I  have  reported  the  al)ove 
cases  rather  than  some  terminating  in  uneventful  recovery,  with  which 
we  are  all  familiar. 


168  ORIGINAL  ARTICLES. 

TRANSACTIONS. 


CLINICAL  SOCIETY  OF  THE  NEW  YORK  POLYCLINIC. 

STATED  MEETING,  MARCH  5,  1906. 

The  President,  JOHN  J.  MacPHEE,  M.  D.,  in  the  Chair.      . 
Reported  by  FREDERIC^  C.  KELLER,  M.D.,  Secretary. 

READING  OF  PAPERS. 
RENAL  COLIC. 

Doctor  Edwwrd  L.  Keves,  Jr.,  read  a  paper  on  this  subject.  He 
said,  in  part:  Renal  colic  is  usually  considered  a  symptom  of  kidney 
stone ;  but  it  is  not  absolutely  pathognomic  of  stone  nor  are  the  position 
and  character  of  the  colic  pains  always  an  infallible  index  of  the  posi- 
tion of  the  stone.  Indeed  so  misleading  is  renal  colic  in  a  certain  few- 
cases,  and  yet  so  rarely  is  it  a  symptom  of  anything  but  stone,  that 
I  think  it  by  no  means  waste  of  energy  to  study  attentively  some  of  the 
cases  which  have  come  under  my  observation  and  in  which  renal  colic 
has  been  a  misleading  and  often  a  confusing  symptom. 

The  late  Doctor  Bryson  once  formulated  in  a  tentative  way  the 
•theory  that  stone  in  the  pelvis  of  the  kidney  causes  pain  in  the  loin 
radiating  down  the  ureter,  while  stone  at  the  lower  end  of  the  ureter 
causes  frequent  and  painful  urination  and  pain  in  the  pelvis.  This 
distinction  holds  true  in  the  great  majority  of  cases;  yet  I  have  seen 
one  case  that  was  a  striking  exception  to  this  rule,  in  that  the  only  pain 
suffered  was  from  frequent  and  painful  urination,  although  the  patient 
had  but  one  stone,  and  that  lay  in  the  pelvis  of  his  kidney. 

The  first  patient,  a  lean  asthmatic  man,  sixty-three  years  old,  com- 
l)lained  of  frequent  urination.  Sixteen  years  ago  he  applied  for 
insurance  and  was  refused  on  account  of  albuminuria.  He  consulted 
a  surgeon,  who  stated  that  he  had  a  surgical  inflammation  of  the 
kidney.  Except  for  the  passage  of  two  calculi  from  thd'  right  kidney, 
eight  and  five  years  ago  respectively,  and  except  that  he  had  to  rise 
once  or  twice  at  night  to  empty  his  bladder,  there  were  no  symptoms 
until  aboni  a  year  a^^o,  when  his  urination  became  more  frequent  and 
he  consulted  an  eminent  urologist  who  began  and  has  since  continued 
treating  him  for  chronic  cystitis  attributed  to  prostatic  hypertrophy. 
His  symptoms  have  grown  gradually  worse. 

Examination  showed  the  right  kidney  to  be  readily  palpable,  some- 
what large  and  tender ;  the  left  kidney  could  just  be  felt,  but  was  not 
tender.  The  urine  was  hazy  with  pus;  specific  gravity  1016;  albumin 
one  per  cent  by  weight ;  various  casts  of  many  kinds ;  many  red  blood 
cells ;  a  total  excretion  of  from  twenty-five  to  thirty  ounces ;  the  bladder 
capacity  was  eight  and  one-half  ounces.  The  prostate  was  not  enlarged ; 
there  was  no  residual  urine.     A'-ray  examination  revealed  a  shad<.Av  in 


CLINICAL  SOCIETY.  169 

the  region  of  the  right'kidney  pelvis,  but  for  various  reasons  the  opera- 
tion was  postponed  for  eighteen  months,  when  the  patient's  condition 
was  so  unsatisfactory  that  it  became  inperative. 

Upon  opening  the  right  kidney,  an  oxalate  stone  was  found  fitting 
in  the  upper  end  of  the  ureter  and  was  removed  through  an  incision 
in  the  kidney  pelvis.  The  kidney  itself  was  considerably  dilated  and 
covered  with  small  cysts  which  contained  serous,  bloody  and  sero- 
purulent  fluid.  It  was  suspected,  because  of  the  nature  of  the  symp- 
toms, that  there  was  a  stone  in  the  ureter,  but  careful  search  failed  to 
reveal  one. 

After  operation,  instead  of  passing  urine  constantly,  as  he  had  done 
heretofore,  he  had  to  be  catherized  until  the  second  day,  when  he  began 
to  urinate  at  intervals  of  from  two  to  four  hours.  The  secretion  of 
urine  remained  low,  and,  finally,  at  the  end  of  three  and  a  half  weeks, 
the  patient  died  from  asthenia  and  failure  of  kidney  function. 

It  is  noteworthy  that  in  this  case  we  were  able  to  arrive  at  a  diag- 
nosis with  the  aid  of  an  A'-ray  photograph,  while  the  practitioner  who 
had  previously  treated  it  had  failed  to  make  the  diagnosis  because  he 
had  not  employed  this  expedient. 

In  contrast  to  the  above  case,  in  which  a  patient  with  stone  suffered 
from  a  pain  that  did  not  resemble  renal  colic,  the  second  case  shows 
the  brilliant  contrast  of  a  patient  with  renal  colic,  but  without  stone. 

The  patient,  fifty-eight  years  of  age,  complained  of  repeated  attacks 
of  renal  colic.  He  never  passed  blood,  never  had  any  anuria  or  bladder 
symptoms,  although  since  the  first  attack  he  had  urinated  twice  at  night 
and  every  three  hours  by  day.  No  lumbar  tenderness  could  be  evoked 
by  palpation,  nor  was  it  possible  to  feel  either  kidney.  X-ray  photo- 
graphs showed  small  sclerotic  kidneys,  but  no  shadow  suggestive  of 
stone.  Examination  of  urine  showed  many  pus  cells,  no  bacteria, 
and  but  very  few  blood  cells.  Macro*scopically  there  was  no  pus.  He 
was  given  an  alkaline  mixture,  advised  to  drink  very  freely  of  water 
and  to  exercise  to  the  limit  of  toleration ;  and  I  believe  that  in  January, 
1906,  he  had  no  further  renal  colic. 

A  detailed  history  is  omitted  of  a  patient  who  suflFered  from  most 
violent  attacks  of  renal  colic  brought  on  by  digestive  causes.  A 
carefully  restricted  diet,  much  exercise  and  water,  and  the  administra- 
tion of  beta-naphthol,  bismuth  and  salol  caused  a  cessation  of  these 
attacks. 

In  further  contrast  to  this  case  was  one,  in  which  the  colic  caused 
by  digestive  disturbance  was  intestinal  and  not  renal,  although  the  pain 
was  precisely  that  of  renal  colic. 

The  last  history  of  which  I  have  record  is  an  example  of  a  class 
of  cases  which  I  consider  very  important.  They  are  relatively  infre- 
quent and  cause  objective  symptoms  absolutely  characteristic  of  renal 
stone;  yet  a  careful  examination  will  reveal  the  fact  that  they  suffer 
from  nothing  more  than  seminal  vesiculitis. 


170  ORIGINAL  ARTICLES. 

RKPORTS  OF  CASES. 
PARTIAL  GASTRECTOMY  FOR  CARCINOMA, 

Doctor  Joseph  I.  Edgerton  :  I  wish  to  present  this  patient,  a  male, 
forty-one  years  of  age.  His  father  is  living  and  in  good  health  at 
seventy-eight;  mother  died  of  stomach  trouble,  probably  cancer,  at 
fifty-eight  years  of  age.  Patient  had  malaria  severely  twenty-five  years 
ago,  but  has  had  no  recurrences.  He  indulges  moderately  in  tea,  coffee, 
and  alcohol,  and  smokes  regularly  from  fifteen  to  twenty  cigarettes 
daily.  For  the  past  thirteen  years  he  suffered  with  heartburn,  which 
has  been  more  constant  during  the  past  two  years,  during  which  time 
he  also  suffered  from  nausea  and  pain  in  the  epigastrium  after  eating. 
During  the  last  few  months  he  had  burning  pains  after  eating;  was 
hungry  all  the  time,  but  afraid  to  satisfy  his  hunger,  for  when  he  took 
solid  food  it  remained  in  the  stomach  for  an  hour  or  so,  and  then 
was  vomited.  On  one  occasion  last  winter  he  vomited  some  mucus 
streaked  with  blood.  He  began  washing  out  the  stomach  twice  a  day 
on  October  4,  and  brought  up  greenish  clumps  of  mucus  resembling 
moss.  There  w^as  no  vertigo.  His  bowels  were  constipated,  and  he 
lost  about  twenty-five  pounds  in  weight  during  the  last  few  months. 

On  November  27,  1905,  the  stomach  contents  contained  free  hydro- 
chloric acid ;  moderate  reaction ;  odor  butyric.  A  mass  could  be  felt 
over  the  region  of  the  pylorus,  and  operation  was  advised  and  accepted 
by  the  patient.  The  usual  preparation  of  cleansing  the  stomach  by 
lavage  was  performed,  and  in  the  operation  Mayo's  technic  was  fol- 
lowed. The  abdomen  was  opened  near  the  median  line  and  the  gastric 
artery  was  doubled,  ligated  and  divided  near  the  cardia.  The  gastro- 
hepatic  omentum  was  also  doubled  and  ligated  close  to  the  liver,  leaving 
most  of  its  structure  attached  to  the  stomach.  The  superior  pyloric 
artery  was  treated  in  the  same  manner,  and  the  upper  inch  or  more 
of  the  duodenum  was  freed.  With  the  fingers  as  a  guide  beneath  the 
pylorus  in  the  lesser  cavity  of  the  peritoneum,  the  right  gastroduodenal 
artery  was  ligated.  The  gastrocolic  omentum  was  cut  distal  to  the 
glands  and  vessels  up,  to  an  appropriate  point  on  the  greater  curvature 
and  the  left  gastroepiploic  vessels  were  ligated.  With  a  running  suture 
of  catgut  through  the  seared  stump  the  end  of  the  duodenum  was 
closed.  The  proximal  end  of  the  stomach  was  double-clamped  along 
the  Miculicz-Hartman  line,  and  divided  with  a  cautery,  leaving  one- 
(juarter  inch  projection.  Then  gastrojejunostomy  was  done.  The 
tumor  was  found  to  occupy  the  pyloric  end  of  the  stomach,  extending 
around  the  whole  circumference.  No  adhesions  were  present.  There 
was  a  delay  in  finding  tftle  nearest  point  of  the  jejunum  that  could  be 
brought  to  the  stomach  wall  and  in  taking  great  pains  to  suture  the 
opening  in  the  mesocolon  so  as  to  prevent  hernia  into  the  lesser  cavity 
of  the  peritoneum. 

His  temperature  at  no  time  following  the  operation  was  above  99.6° 
Fahrenheit,  and  there  has  been  no  vomiting  since  operation.  He  took 
water   in   eight   hours  and   liquid   nourishment   in   twenty-four.     His 


CLINICAI-  SOCIETY.  171 

bowels  were  moved  by  enemas  during  the  first  week,  but  there  was  no 
distention ;  in  fact,  no  more  discomfort  than  from  an  ordinary  explora- 
tory laparotomy  alone.  The  man  has  gained  about  twenty-five  pounds 
in  weight  and  is  at  his  regular  employment  again  with  no  discomfort 
whatever  referred  to  his  stomach. 

CASE  OF  MORPHINE  POISONING, 

Doctor  Daniel  A,  Sinclair  :  I  wish  to  report  the  case  of  a  patient 
who  is  sixty-three  years  of  age,  weighs  one  hundred  eighty  pounds,  is 
five  feet  six  inches  in  height,  full  blooded,  with  marked  organic  heart 
disease.  He  has  been  coming  to  my  office  for  the  past  two  or  three 
years  suffering  from  alcoholism.  He  is  a  periodic  drinker,  and  when 
first  seen,  two  or  three  years  ago,  had  been  treated  along  the  regular 
lines  for  such  a  condition.  He  freely  informed  me  that  he  had  been 
in  the  habit  of  receiving  injections  of  morphine  from  previous  doctors 
and  that  was  the  only  treatment  that  did  him  any  good.  Accordingly 
one-quarter  of  a  grain  of  morphine  was  injected,  which  the  patient 
reported  at  the  next  visit  was  of  no  benefit  whatever,  stating  that  it 
was,  he  knew%  a  very  small  amount — nothing  like  what  he  had  been 
used  to  getting.  The  dose  of  morphine  was  very  carefully  increased 
to  one-half  grain  without  any  effect,  and  finally,  at  the  earnest  solicita- 
tion of  the  patient  and  his  assurances  that  he  could  stand  the  morphine, 
the  dose  was  increased  to  one  grain.  This  injection  bore  out  his  state- 
ments as  to  his  previous  experiences  and  "just  about  steadied  him," 
without  producing  anything  but  a  very  short  sleep.  His  subsequent 
periodic  sprees  were  treated  along  the  same  lines,  from  three-quarters 
to  one  grain  being  used  at  an  injection.  It  became  so  much  a 
matter  of  course  to.  inject  this  patient  and  see  no  untoward  effects 
whatsoever  that  there  was  no  hesitation  about  giving  him  a  grain  of 
morphine  two  or  three  times  a  day,  according  to  the  exigencies  of  the 
occasion.  Between  the  sprees  the  man,  who  was  of  more  than  average 
intelligence,  not  only  abstained  from  alcohol,  but  did  not  have  the 
slightest  desire  for  morphine  or  any  other  drug. 

The  treatment  detailed  above  was  carried  out  until  the  last  spree, 
about  a  month  ago.  On  this  occasion  he  presented  himself,  intoxicated, 
but  retaining  all  his  faculties,  and  begged  for  an  injection  of  morphine, 
saying  that  he  would  only  be  put  "on  the  ragged  edge,"  as  he  expressed 
it,  if  he  received  the  usual  dose.  He  stated  that  he  had  taken  as  many 
as  three  grains  of  morphine  without  any  bad  effects,  but  this  statement 
he  afterward  denied.  He  had  a  very  important  meeting  for  the  next 
day,  and  therefore  was  desirous  of  securing  a  good  night's  rest.  One 
and  one-half  grains  of  morphine  sulphate  were  injected  into  his  left 
arm.  In  about  half  an  hour  I  was  called  to  him  hurriedly,  and  found 
him  in  a  much  stupified  condition.  This  was  about  8  p.  m.  ;  a  small 
dose  of  cocain  was  injected  and  I  left,  returning  about  9  o'clock,  when 
the  patient  was  breathing  slowly,  about  five  or  six  a  minute.  He  was 
walked  up  and  down  until  about  1 1  o'clock,  at  w^hich  time  his  respira- 
tions had  diminished  to  one  in  two  minutes.     Up  to  this  time  there  had 


172  ORIGINAL  ARTICLES. 

been  injected  hypodermatically  3/5  of  a  grain  of  cocain,  4/150  of 
atropine  sulphate,  4/30  of  strychnine  and  4/100  of  nitroglycerine. 
He  had  also  been  given  about  a  quart  of  strong,  black  coffee.  The 
situation  being  desperate,  at  the  request  of  the  man's  family  1/12  of 
apomorphine  sulphate  was  injected  as  an  emetic  and  was  effectual  in 
about  one-half  minute.  The  patient  went  steadily  into  a  deep  coma, 
became  very  blue  and  was  apparently  dying.  Artificial  respiration 
and  the  administration  of  oxygen  were  then  resorted  to  and  the  tongue 
pulled  forward  with  artery  forceps.  At  1 130  p.  m.  he  began  breathing 
at  the  rate  of  about  four  a  minute.  About  a  quart  of  black  coffee  was 
given  as  an  enema  and  about  3  a.  m.  he  was  breathing  about  ten  times 
a  minute  and  was  conscious. 

The  oxygen  and  artificial  respiration,  together  with  the  cocain, 
probably  saved  the  man's  life.  Two  lessons  should  be  learned  from 
this  case :  ( i )  Not  to  be  importuned  into  giving  any  patient  a  large 
dose  of  morphine,  even  though  he  is  used  to  it ;  and,  (2)  not  to  abandon 
hope  or  relax  one's  efforts,  even  when  the  patient  is  apparently  beyond 
hope,  as  this  case  show^s  that  even  in  apparently  fatal  cases  life  may 
be  saved. 

DISCUSSION. 

Doctor  Robert  IT.  M.  Dawbarn  :  This  case  recalls  to  my  mind  a 
case  of  morphine  poisoning  which  occurred  when  I  was  interne  at  the 
Nursery  and  Child's  Hospital.  I  placed  the  patient  on  his  back  and 
administered  atropine  (the  first  dose  of  which  dilated  the  tubes)  until, 
from  morphine  poisoning,  the  patient  developed  a  case  of  atropine 
poisoning.  Life  was  saved  by  artificial  respiration,  which  was  kept 
up  for  eight  hours  by  myself  and  assistant,  each  taking  two-minute 
turns.  Walking  the  patient  up  and  down  was  tried,  but  the  exertion 
seemed  only  to  make  the  heart  w^eaker.  If  I  were  to  criticise  the  treat- 
ment of  the  case  under  discussion,  it  would  be  the  giving  of  depressing 
narcotics,  as  after  vomiting  from  an  overdose  of  morphine  the  patient 
usually  collapses. 

Doctor  Maurice  Packard  :  In  a  series  of  experiments,  in  which  I 
have  been  interested,  which  were  being  conducted  by  Doctors  Bodine 
and  Jeffries,  they  were  trying  to  find  out  from  guinea  pigs  how  much 
morphine  w^ould  act  as  an  antidote  for  a  given  injection  of  cocain, 
acting  upon  the  principle  that  cocain  is  a  physiological  antidote  for 
morphine.  Previously  atropine  had  been  used  for  this  purpose,  but 
atropine  and  morphine  acted  similarly,  in  that  both  have  a  tendency 
to  depress  the  smooth  muscle  fibres  as  well  as  secretion,  while,  on  the 
other  hand,  cocain  stimulates  the  smooth  muscle  fibres  and  increases 
secretion,  as  is  shown  by  the  druling  at  the  mouth  and  the  frequency 
of  urination.  The  best  possible  treatment,  I  think,  is  the  stomach 
tube.  After  using  it  once,  however,  it  must  be  used  every  half  hour, 
for  the  mucous  membrane  of  the  stomach  repeatedly  secretes  morphine. 
With  the  stomach  tube  and  the  proper  use  of  cocain,  most  of  these 
cases  will  end  in  recovery. 


DIAGNOSTIC  SIGNIFICANCE  OF  COLIC.  173 

ORIGINAL  ABSTRACTS. 


MEDICINE. 

By  GEORGE  DOCK,  A.M.,  M.  D.,  D. Sc.  Ann  Arbor.  Michigan. 

PKOPBSSOR  or   MBDICINB  IN  THB  UNIVBRSITY  09  MICHIGAN. 

AND 

DAVID  MURRAY  COWIE,  M.  D.,  Ann  Arbor.  Michigan. 

FIRST  ASSISTANT  IN  MBDICINB  IN  THB   UNIVBRSITY  OV   MICHIGAN. 


HYPERTROPHIC  STENOSIS  OF  THE  PYLORUS. 

Rogers  (Archives  of  Pediatrics,  March,  1906)  reports  a  case  of 
hypertrophic  stenosis  of  the  pylorus  in  an  infant  of  three  weeks.  Med- 
ical treatment  was  persisted  in  until  the  third  month,  when  operation 
by  posterior  gastro-jejunostomy  was  performed.  Patient  recovered. 
The  symptoms  of  nearly  complete  stenosis  of  the  pylorus  in  children 
are  very  stereotyped,  and  in  the  beginning  of  the  gastric  disturbance 
they  are  always  suggestive.  Any  considerable  amount  of  food  in  the 
stomach  nine  hours  after  the  last  meal,  as  was  observed  in  the  author*s 
case,  especially  if  present  on  more  than  one  occasion  and  accompanied 
by  other  symptoms  of  obstruction,  should  always  determine  the  advisa- 
bility of  immediate  surgical  interference.  This  case  well  illustrates  the 
hopelessness  of  medical  treatment.  Improvement  from  time  to  time 
will  raise  the  hope  that  operative  measures  may  not  be  necessary.  Such 
improvement  is  usually  deceptive.  Rogers'  case  is  the  third  successful 
operative  case  reported  from  this  country.  The  operation  was  per- 
formed under  ether  and  occupied  twenty-five  minutes.  d.  ^r.  c. 


SURGERY. 

By  frank  BANGHART  WaLKER,  Ph.  B.,  M.  D.,  Detroit,  Michigan. 

rROVBSSOR   OV  SURGBRT  AND  OPBKATIVR  SURGRRY   IN  THB   DETROIT  POSTGRADUATB  SCHOOL  OP   MBDICINB; 
ADJUNCT  PROPRSSOR  OP  OPBl(ATIV8  SURGBRY   IN  THB   DBTROIT  COLLBG8  OP   MBDICINB. 

AND 

CYRENUS  GARRITT  DARLING.  M.  D.,  Ann  Arbor.  Michigan. 

CLINICAL  PROPBSSOR  OP  SURGBRT  IN  THB  UNIVBRSITY  OP   MICHIGAN. 


THE  DIACiXOSTIC  SIGNIFICAX'CE  OF  COLIC. 

In  the  Nezv  York  Medical  Journal,  Volume  LXXXIII,  Number 
XII,  La  Roque  brings  out  the  characteristic  features  of  colic  from  dif- 
ferent sources  and  contrasts  it  with  peritonitis. 

He  refers  to  the  common  inclusion  of  most  manifestations  of 
abdominal  pain  under  the  term  colic  but  thinks  it  should  be  limited  to 
designate  spasmodic  involuntary  muscular  contraction  of  the  walls  of 
an  intraabdominal  viscus  or  canal.  The  commonest  causes  he  states 
are  found  in  the  gastrointestinal  tract,  biliary  and  pancreatig  passages. 


174  ORIGINAL  ABSTRACTS. 

urinary  apparatus  and  female  generative  organs.  They  may  be  inci- 
dent to  irritative  lesions  as  inflammation  or  fermentation  and  their 
products,  including  gaseous  distention,  to  obstructive  lesions  as  foreign 
bodies,  invagination,  torsion  and  constriction  from  without,  and  to 
nervomuscular  incoordination  as  in  lead  poisoning  and  certain  other 
intoxications. 

Certain  symptoms  are  common  to  all  varieties  of  colic,  as  the 
paroxysmal  pain,  its  sudden  onset  and  griping  character,  restlessness, 
et  cetera.  Certain  other  symptoms  are  referable  to  functional  or 
anatomic  alterations  in  the  structure  involved.  In  affections  involving 
principally  the  stomach  the  pain  is  referred  chiefly  to  the  epigastrium. 
Colicky  pain  of  the  intestine  is  often  most  severe  in  the  region  about 
the  umbilicus.  Diarrhea  generally  indicates  intestinal  disease,  and  the 
intensity  of  it  is  greatest  in  diffuse  colonic  disease.  In  general  the 
darker  and  more  intimately  mixed  is  the  blood  in  the  feces,  the 
higher  is  its  origin.  The  false  diarrhea  incident  to  mechanical  obstruc- 
tion about  the  ileocecal  junction  is  scanty,  mucoid,  often  bloody  in 
character,  with  little  fecal  matter  and  often  associated  with  tenesmus. 
Ihe  spasmodic  vomiting  of  colic  is  expulsive,  often  violent,  and  in 
general  it  may  be  said  that  the  intensity  of  vomiting  varies  directly 
with  the  height  of  the  lesion  and  inversely  with  the  severity  of  the 
diarrhea.  Except  in  intestinal  obstruction,  however,  vomiting  is  never 
stercoraceous.  Colic  is  usually  the  first  symptom  of  plumbism.  The 
chief  diagnostic  features  are :  Constipation,  flat  or  retracted  rigid  belly, 
associated  cramps  in  other  muscles,  slow,  wiry  pulse  and  the  absence 
of  all  signs  of  intraabdominal  inflammation.  In  connection  with  tabes 
colic  may  be  gastrointestinal,  renal,  ureteral,  vesical,  and  even  rectal, 
bronchial,  laryngeal  and  other  affections  are  not  unheard  of.  Biliary 
colic  begins  and  is  most  severe  in  the  region  of  the  gall-bladder,  from 
which  it  radiates  along  the  course  of  the  intercostal  nerves  to  the  right 
scapula.  Pancreatic  colic  is  not  frequent.  Renal  or  ureteral  colic 
begins  over  the  region  of  the  kidney  and  radiates  downward  and  ante- 
riorly. Uterine,  tubal  and  ovarian  colic  are  commonly  combined  and 
often  indistinguishable.  Pelvic  examination  generally  detects  the 
cause. 

In  every  case  of  abdominal  pain  the  phenomena  of  colic  must  be 
immediately  differentiated  from  those  of  peritonitis.  The  author  has 
presented  the  following  table: 

PAIN. 

Colic.  Peritonitis. 

Less  sudden  onset.  *  !More  sudden  onset. 

Gradually  rising  to  maximum.  May  be  preceded  by  the  pain  of  the 

Waxing    and    waning    in    intensity.  primary  lesion. 

Paroxysmal.  No  spontaneous  waning  in  intensity, 

Less  positively  localized  to  a  point  of  persistently  severe,  often  positively 

greatest  intensity.  localized,  and  unless  diffuse,  there 

is  always  a  point  of  greatest  inten- 
siiv. 


DIAGNOSTIC  SIGNIFICANCE  OF  COLIC.  175 

DECUBITUS. 

Generally  doubled  up,  patient  may  lie  Thighs  may  be  flexed,  but  no  positive 

in    any    position.      Restlessness    is  doubling   up.     Dorsal   decubitus   is 

marked  by  frequent  changes  in  po-  generally  assumed,  and  instinctive- 

sition.  ly  maintained. 

VOMITING. 

May  or  may  not  occur,  when  present  Practically  always  occurs,  and  is  of 

is  expulsive  in  type.  the  easy  type. 

BOWELS. 

Constipation    only   accidental    except  Constipation   marked   though   purg^- 

in    intestinal    obstruction    and    in  tives  in  large  doses  may  be  effect- 

plumbism.  ive. 

Purgatives  are  effective  except  in  ob-  Diarrhea  never  present  except  in  per- 

struction.  itonitis  arising  from  pelvic  organs. 
Diarrhea  may  be  a  part  of  symptom 

complex. 

PERISTALSIS. 

Normal  or  exaggerated.  Never  exaggerated. 

Absent  in  the  segment  of  gut  in- 
volved, but  in  local  peritonitis  this 
is  difficult  to  determine. 

TENDERNESS. 

Cutaneous    sensibility    greatly    cxag-  Skin  tenderness  insignificant  as  com- 

gerated,  broad,   steady,   deep  pres-  pared    with    the    fixed    deep-seated 

sure    is   grateful,    though   a   vague  excruciating  tenderness, 

deep  seated  tenderness  of  the  caus- 
ative lesion  may  be  elicited. 

MUSCULAR   RIGIDITY. 

Never  positive  nor  continuous  except  Always  reflex  and  continuous.     Not 

in    plumbism    or   great    distention.  easily   overcome   by   pressure.      In 

May  be  overcome  by  gentle,  steady  localized    disease   may   be   circum- 

pressure,  and  is  not  confined  to  a  scribed, 
small  circumscribed  area. 

DLM'HRAGMATIC   MOBILITY. 

Never  impaired  except  by  great  dis-  Generally    reflexly   diminished,   espe- 

tention.  cially  when  the  upper  abdomen   is 

Movements  are  not  generally  causa-  involved.     Sudden  eflforts,  such  as 

tive  of  pain.  coughing  and   deep  breathing,   are 

painful. 

METEORISM. 

May  or  may  not  occur,  not  charac-  Generally     noted     early,     though     in 

teristic  except  in  obstruction.  many  cases  slight,  till   disease  be- 

comes well  marked. 

LEUC  OCYTOSIS. 

Rarely   present,   and   never   progres-  May  not  be  present,  but  generally  ex- 

sive.  ists,  and  if  nrogressive.  is  of  diag- 

nostic value. 

FEVER. 

May  or  may  not  exist.    A  sudden  fever,  especially  if  preceded  by  rigor,  points 
to  peritonitis,  though  its  absence  is  perfectly  compatible  with  this  disease. 


176  ORIGINAL  ABSTRACTS. 

GYNECOLOGY, 


By  REUBEN  PETERSON,  A.  B..  M.  D.,  Ann  Arbor,  Michigan. 

PROPBSSOR  OP  GTNSCOLOGT  AND  OBSTBTKICS  IN  TKB  UNIVBKSITY  OF  MICHIGAN. 

AND 

CHRISTOPHER  GREGG  PARNALL,  A.  B.,  M.  D..  Ann  Arbor,  Michigan. 

PIRST  ASSISTANT  IN  GTNBCOLOGT  AND  OBSTETRICS  IN  THB  UNIVBRSITY  OP  MICHIGAN. 


DU  M£AT  HYPOGASTRIQUE  ET  DE  UEPISIORRAPHIE 

APPLIQUfiE  AU  TRAITMENT  DE  CERTAINES  FIS- 

TULES  UR£THRO-V6SICO-VALGINALES. 

CiiENiEUX  {Reviie  de  gynecologic  et  de  chirurgie  abdominale,  Vol- 
ume X,  Number  I)  describes  an  operation  for  certain  cases  of  urethro- 
vesico-vaginal  fistulae.  This  operation  is  to  be  used  only  in  rare  cases., 
for  exceptional  indications,  when  other  procedures  have  failed,  or 
would  fail  if  employed.  In  the  repair  of  urinary  fistulae  the  object  is 
to  restore  control.  Under  various  circumstances  this  cannot  be  done, 
for  instance,  in  cases  where  the  adhesions,  the  extent,  or  the  location 
of  the  fistulous  opening  are  such  that  complete  closure  is  impos- 
sible, or  when  the  sphincter  of  the  bladder  is  involved  so  that  repair  of 
the  fistula  will  not  cure  the  incontinence. 

The  writer  reports  a  case  in  which  he  employed  his  operation.  A 
woman,  aged  twenty-six,  after  a  difficult  labor,  suffered  from  inconti- 
nence of  urine.  Marked  leakage  took  place  without  regard  to  the 
position  assumed.  ILxamination  showed  practically  a  destruction  of 
the  cervix  and  the  anterior  vaginal  wall.  The  borders  of  the  extensive 
fistula  were  indurated  and  adherent  at  the  sides  to  the  pelvic  bones, 
posteriorly  to  the  remains  of  the  uterus.  The  fistula  was  classified  as 
urethro-vesico-vaginal,  for  the  whole  urethra  as  well  as  the  floor  of 
the  bladder  had  disappeared.  Such  cases  are  extremely  rare  and  can- 
not be  treated  by  any  of  the  more  common  operative  procedures. 

The  method  used  in  this  case  was  a  modification  of  that  practiced 
by  Maisonneuve,  Baker-Brown,  and  Rose,  and  consisted  in  the  estab- 
lishment of  a  communication  between  the  bladder  and  the  rectum  with 
closure  of  the  vaginal  and  urethral  openings.  The  operation  is  done 
by  making  two  large  lateral  flaps  consisting  each  of  one  labium  majus 
with  the  surrounding  tissue.  The  base  or  pedicle  of  one  flap  lies  in  a 
line  from  the  anterior  commissure,  along  the  edge  of  the  introitus,  to 
the  center  of  the  perineum.  The  base  of  the  second  flap  lies  well  out 
at  the  fold  forming  the  junction  of  the  skin  of  the  thigh  and  vulva. 
The  first  flap  is  now  turned,  raw  surface  outward,  into  the  bed  formed 
by  dissecting  loose  the  other  flap,  and  sutured  in  place.  The  second 
flap  is  now  shifted  over  the  raw  surface  to  cover  it  with  skin.  This 
fla])  is  now  sutured  to  the  margin  of  the  incision  which  outlined  the 
first  flap.  In- this  way  the  meatus  and  the  vaginal  orifice  are  securely 
closed.  The  opening  between  the  vagina  and  the  rectum,  which  is 
made  before  the  vulvar  introitus  is  occluded,  is  utilized,  subsequently. 


SUBSTITUTE  FEEDING  IN  INFANTS.  177 

as  an  avenue  through  which  a  canula  with  an  obturator  is  passed  to 
irrigate  the  vesical  portion  of  the  artificial  cloaca,  in  order  to  prevent 
the  formation  of  calculi.  With 'proper  instruction,  the  patient  herself 
will  be  able  to  carry  out  this  procedure. 

The  results  of  the  operation  are  not  fully  stated.  The  writer  does 
not  discuss  the  possibility  of  ascending  infection  of  the  urinary  tract 
and  no  idea  is  given  as  to  how  long  the  patient  could  retain  urine.  A 
difficulty  experienced  by  some  surgeons  after  similar  operations  is  con- 
traction of  the  edges  of  the  artificial  fistula  between  the  vagina  and  the 
rectum,  necessitating  a  more  extensive  opening  by  a  subsequent  oper- 
ation, c.  G.  p. 


PEDIATRICS. 

By  ARTHUR  DAVID  HOLMES,  M.  D.,C.  M.,  Detroit,  Michigan* 


SUBSTITUTE  FEEDING  IN  INFANTS. 

Sanderson  Wells  (Sritish  Medical  Journal,  July  8,  1905)  says 
any  food  not  conforming  with  the  standard  composition  and  properties 
of  mother's  milk  must  be  rejected.  He  says  artificial  foods  as  a  class 
are  bad,  and  believes  wet-nursing  inadvisable  as  it  is  inaccurate,  incon- 
venient and  dangerous,  because  we  cannot  exclude  syphilis.  The  author 
relies  on  the  modification  of  cow*s  milk  and  draws  the  following 
conclusions : 

(i)  That  mother's  milk  is  the  only  proper  food  for  infants  and 
should  be  used  whenever  available. 

(2)  That  all  forms  of  proprietary  foods  are  bad  and  to  be  avoided. 

(3)  That  wet-nursing  is  rarely  permissible. 

(4)  That  the  proper  substitute  food  for  infants  is  some  form  of 
modified  cow's  milk. 

Also  the  following  special  conclusions: 

(i)  That  the  standard  at  which  we  aim  in  modifying  cow's  milk 
is  the  child's  natural  food — mother's  milk. 

(2)  That  careful  attention  must  be  paid  to  each  of  the  constituents — . 
proteid,  fat,  sugar  and  salts. 

(3)  That  the  proteid  of  cow's  milk  is  less  digestible  than  that  of 
human  milk  and  requires  overdilution  compared  with  that  of  the 
standard. 

(4)  That  the  whole  of  this  indigestible  proteid  (caseinogen)  may 
be  removed,  leaving  the  more  easily  digestible  proteid  (lactalbumen) 
as  in  whey  mixtures,  or  that  the  proteid  content  may  be  completely  or 
partially  peptonized. 

(5)  That  cow's  milk  diluted  sufficiently  to  bring  the  proteid  into 
line  with  the  standard  (that  is,  from  four  per  cent  to  1.5  per  cent)  is 
deficient  in  fat  and  sugar,  and  that  these  must  be  subsequently  added. 

(6)  That  fat  may  be  added  in  the  form  of  cream,  either  separated 
and  of  standard  strength,  or  by  using  gravity  creams. 

(7)  That  lactose  is  the  proper  sugar  to  add. 


178  ORIGINAL  ABSTRACTS. 

(8)  That  cow's  milk,  although  neutral  or  alkaline  when  drawn, 
owing  to  its  certain  infection  as  at  present  obtained  and  to  the  rapid 
growth  of  germs  it  allows,  beccMnes  acid,  and  that  this  acidity  must  be 
neutralized  by  bircarbonate  of  soda  or  limewater. 

(9)  That  human  milk  is  sterile.  From  this  it  follows  that  we  should 
endeavor  by  all  the  means  in  our  power  to  obtain  a  supply  of  sterile 
cow's  milk. 

(10)  Germs  must  be  killed  by  some  method.  The  handiest  and 
most  generally  used  being  heat. 

To  his  previous  conclusions  he  adds  the  following : 

( 1 )  That  some  attempt  must  be  made  to  kill  germs  always  present 
in  large  quantities  in  milk. 

(2)  That  boiling  does  this  most  effectually  and  rapidly,  is  much 
the  easier  method,  and,  in  the  hands  of  the  poor,  often  the  only  method 
available,  but  that  certain  injurious  changes  result,  to  be  avoided  if 
possible. 

(3)  That  these  changes  can  best  be  avoided  at  70°  centigrade 
(158°  Fahrenheit)   for  half  an  hour  (Pasteurization). 

(4)  That  all  infant's  food  should  therefore  undergo  this  process 
when  possible.  

ORTHOPEDICS. 

By  IRA  DEAN  LOREE,  M.D.,  Ann  Arbor,  Michigan. 

FIRST  ASSISTANT  IN  SUKGBRY  IN  THE   UNIVBKSITY  OF   MICHIGAN. 


CONGENITAL  COXA  VARA. 

Henry  O.  Feiss,  M.  D.,  of  Cleveland,  in  Jamaj  February  24,  1906. 

He  gives  the  history  of  one  case  with  arguments  favoring  its  origin 
as  intrauterine.  The  article  contains  a  summary  of  certain  experiments 
performed  upon  the  dead  fetus.  These  consisted  in  fixing  the  limbs 
in  certain  positions  that  might  be  assumed  before  birth  and  then  noting 
the  relations  of  the  parts  by  means  of  the  radiograph. 

He  concludes  that  the  deformity  comes  most  commonly  with  defects 
of  the  femur  of  the  lower  limbs.  That  it  may  be  intrauterine  in  its 
strictest  sense,  from  intrauterine  infection  or  combined  with  congenital 
rachitic  deformities. 


LARYNGOLOGY. 

By  WILLIS  SIDNEY  ANDERSON,  M.  D.,  Detroit,  Michigan. 

ASSISTANT  TO  THB  CHAIR  OF  LARYNGOLOGY  IN  THB  DETROIT  COLLEGE  OF  MEDICINE. 


A  CONTRIBUTION  TO  THE  STUDY  OF  THE  ETIOLOGY 
OF  NASAL  OBSTRUCTION. 
WiLHELM  RoTH  (Rcvue  Hebdomodoire  de  Laryngologie,  d'Otolo- 
gie  et  de  Rhinologie,  January  20,  1906)  calls  attention  to  those  cases 
where  the  antrum  of  Highmore  is  involved,  and  where  the  secretion 
is  of  such  consistence  that  none  of  it  flows  out  into  the  nasal  fossa. 


r 


SPHINCTER  AND  FISSURE.  179 

Examination  of  the  nose  shows  no  secretion,  nor  the  usual  evidence 
of  sinus  involvement.  These  cases  are  accompanied  by  nasal  obstruc- 
tion of  the  side  corresponding  to  the  sinus  involved.  The  swelling  in 
the  nose  involves  the  cavernous  tissue,  and  it  promptly  shrinks  after 
the  application  of  cocain.  No  anatomical  reason  can  be  found  to 
account  for  the  nasal  obstruction.  If  the  antrum  be  thoroughly 
washed  out,  the  nasal  obstruction  will  promptly  disappear.  If  the 
secretions  are  again  allowed  to  accumulate  in  the  sinus,  the  nasal 
obstruction  will  recur.  The  author  believes  that  the  cause  of  the 
swelling  of  the  cavernous  tissue  is  the  reflex  vasomotor  irritation  due 
to  the  accumulation  of  the  secretion  in  the  sinus.  Roth  holds  that  this 
type  of  sinus  disease  is  an  important  factor  in  the  etiology  of  unilateral 
nasal  obstruction,  where  no  anatomical  cause  can  be  found  to  account 
for  the  nasal  condition. 


PROCTOLOGY. 

By  LOUIS  JACOB  HIRSCHMAN,  M.  D.,  Detroit,  Michigan. 

CLINICAL  PROVKSSOR  OV  PROCTOLOGY  IN  THB  DBTROIT  COLLBCR  OP  MRDICINB. 


DIVULSION  OF  THE  SPHINCTER,  AND  FISSURE  IN  ANI. 

DwiGHT  H.  Murray^  under  the  caption,  "Some  Minor  Rectal 
Lesions,"  treats  of  a  number  of  ano-rectal  conditions,  in  the  Buffalo 
Medical  Journal,  Volume  LXI,  Number. IX. 

Speaking  of  divulsion  of  the  sphincter  muscle,  he  judges,  from  the 
statements  of  many  physicians  and  patients  with  whom  he  has  come  in 
contact,  that  that  procedure  is  not  well  understood.  At  least  ten  min- 
utes, on  an  average,  should  be  occupied  in  this  procedure.  The  muscle 
should  be  carefully  and  slowly  tired  out,  or  paralyzed,  not  quickly 
stretched  and  the  muscular  fibers  torn.  Murray  has  had  patients  who 
gave  a  history  of  rapid  dilation  of  the  sphincter,  which  resulted  in  a 
partial  loss  of  sphincteric  control.  Rectal  operations  done  after  a  proper 
divulsion  cause  much  less  pain,  and  a  soreness  only  is  complained  of  in 
most  cases. 

Fissure  in  ani,  at  the  onset  is  indicated  by  a  sharp  cutting,  tearing  or 
burning  pain  coming  on  during  or  after  a  bowel  movement.  Patients 
do  not  always  know  just  the  time  it  began ;  they  may  first  notice  a  little 
bleeding  after  stool,  sphincteric  spasm,  and  an  increased  constipation 
caused  by  fear  of  pain.  The  stool  then  may  become  dry  and  hard, 
making  the  fissure  worse.  These  patients  are  in  a  very  nervous  condi- 
tion with  many  direct  and  reflex  symptoms.  Sometimes  the  only  symp- 
tom of  an  anal  fissure  is  a  pain  in  the  heel,  which  is  often  treated  for 
rheumatism. 

Recent  fissures,  if  there  is  no  spasm  of  the  sphincters  or  induration, 
may  be  successfully  treated  without  operation.  Orthoform  applied  to 
its  base,  followed  by  pure  ichthyol  applied  every  other  day,  is  an  excel- 
lent treatment  for  most  nonoperative  cases.    Uncomplicated  cases  are 


180  EDITORIAL  COMMENT. 

cured  under  this  treatment  in  from  two  to  four  weeks.  Operation  is 
indicated  in  cases  with  hypertrophied,  hard,  spasmodically  contracted 
sphincter,  and  a  sentinel  pile  well  developed.  Dilation,  incision  and 
excision  are  the  operative  procedures,  and  their  names  are  self- 
explanatory. 


EDITORIAL  COMMENT. 


MEDICAL  CLASSICS  IN  MEDICAL  MEETING. 
Notwithstanding  the  important  position  which  medical  literature 
occupies  in  the  domain  of  medicine,  students  are  taught  practically 
nothing  in  medical  college  regarding  the  classic  works  which  reach 
across  the  centuries  of  medical  history  and  chronicle  the  representative 
thought  and  practice  of  the  various  periods,  while  physicians  are  seldom 
afforded  opportunity  for  bibliographic  research  in  medical  meeting. 
Owing  to  the  factor  of  time  in  the  career  of  the  average  practitioner, 
there  is  doubtful  possibility  of  acquiring  extensive  concrete  knowledge 
concerning  the  glories  of  the  guild  until  the  curriculum  of  every  medical 
college  includes  a  course  in  the  history  of  medicine.  The  subject 
receives  considerable  attention  in  Europe,  but  probably  not  more  than 
a  half  dozen  American  colleges  impart  instruction  of  this  nature. 

*     *     * 

A  feature  of  the  Ann  Arbor  meeting  of  the  First  Councilor  District 
Medical  Society  of  Michigan  was  an  exhibit  by  Doctor  George  Dock  of 
some  representative  medical  books  from  his  private  library.  Lack  of 
space  determined  the  number  of  volumes  shown  to  a  certain  extent, 
and  the  works  selected  were  chosen  to  represent  important  phases  of 
medical  history  especially  in  the  modern  period  and  after  the  rise  of 
pathologic  anatomy.  The  volumes  were  arranged  as  given  below,  so 
as  to  follow  an  order  partly  chronologic,  partly  topical.  They  were 
open  to  show  important  or  interesting  passages,  and  each  volume  bore 
a  card  with  the  author's  name,  dates  and  other  particulars,  as  in  the 
list  below,  taken  from  these  cards.  The  exhibit  gave  a  bird's-eye  view 
of  some  of  the  most  interesting  periods  of  medical  history.  Some  of 
the  books,  as  the  "Rosa  anglica"  and  the  *'Auenbrugger,"  are  exceed- 
ingly rare. 

sK       sK       • 

John  of  Gaddesden,  also  called  Johannes  Anglicus.     Died  about 

1350. 

The  "Doctor  of  Physic"  of  the  "Canterbury  Pilgrimage";  Court 
Physician. 

A  copy  of  his  "Rosa  anglica,"  a  compend  of  medicine.  This  is  the 
Venice  1902  edition,  erroneously  called  the  15 16  edition.  The  first 
edition  was  printed  in  1492. 

The  contents  give  a  good  idea  of  the  medicine  of  six  hundred  years 


B 


MEDICAL  CLASSICS.  181 

ago.     The  mdrk  shows  the  celebrated  passage  regarding  the  use  of  red 
light  in  smallpox. 

Translation  from  the  section  on  "Treatment  ('Cura')  of  Variola:" 
"Let  scarlet  be  taken  and  let  him  who  is  suffering  smallpox  be  entirely 
wrapped  in  it  or  in  some  other  red  cloth.  Thus  I  did  when  the  son  pf 
the  illustrious  King  of  England  suffered  from  the  smallpox.  I  took 
care  that  everything  about  the  couch  should  be  red  and  his  cure  was 
perfectly  effected,  for  he  was  restored  to  health,  without  a  trace  of  the 
pocks." 

Glisson,  Francis.  1597-1677.  (Described  Glisson's  capsule.) 
The  first  edition  (1650)  of  his  work  on  "Rickets,"  the  first  mono- 
graph on  disease  published  in  England,  except  that  of  Caius  (died 
1563)  on  "Sweating  Sickness,"  a  much  less  thorough  work.  One  of 
the  glories  of  English  medicine.  To  Glisson's  description  of  the  mor- 
bid anatomy  as  observed  by  the  naked  eye,  subsequent  writers  have 
added  little. 

BONETUS,  ThEOPHIL.       162O-1689. 

The  first  (1679)  edition  of  the  "Sepulchretum  anatomicum,"  the 
brilliant  beginning  of  pathologic  anatomy,  a  storehouse  of  the  most 
important  observations  recorded  up  to  that  time. 

Mueller,  Johannes.     1801-1885. 

"Ueber  den  feineren  Bau  und  die  Formen  der  krankhaften  Gesch- 
wuelste."     1850. 

This  work  is  all  Mueller  finished  of  a  projected  treatise  on  the 
"Histology  and  Classification  of  Tumors."  It  represents  the  first 
fruitful  application  of  the  microscope  to  the  study  of  pathologic 
anatomy.  One  of  the  only  two  unfinished  works  left  by  this  great 
genius,  the  master  of  Virchow,  Helmholtz,  DuBois  Reymond,  and  the 
most  important  figure  in  the  history  of  nineteenth  century  medicine. 

"Die  Medicine  Reform.'' 

Founded  by  Virchow  and  Leubuscher  July,  1848,  with  the  object  of 
hastening  reforms  in  university  education;  medical  education  and 
organization;  care  of  the  sick  and  the  poor;  administration  of  hospi- 
tals; the  appointment  of  a  Minister  of  Medicine  for  Prussia  was 
demanded,  and  a  Ministry  of  Public  Health  and  Medical  Laws  for  all 
Germany.  "A  Reform  of  Science  and  of  Society."  The  journal  was 
given  up  at  the  end  of  one  year  on  account  of  the  failure  of  the  revolu- 
tion and  the  impossibility  of  a  reorganization  of  public  health,  medical 
education,  and  the  medical  profession. 

Virchow,  Rudolph.     1821-1902. 

First  edition  of  the  "Cellular  Pathologic." 

Showing  the  relations  of  pathology  and  medicine  to  the  cell  doc- 
trine, and  the  intimate  changes  in  the  tissues  and  organs,  on  which  the 
whole  of  modern  medicine  is  based.  No  one  before  Virchow  expressed 
the  belief  that  the  phenomena  of  disease,  like  other  biologic  phenomena, 
are  the  expressions  of  cellular  activity,  a  belief  that  only  becomes 
strengthened  by  the  advance  of  knowledge. 


182  EDITORIAL  COMMENT. 

First  volume  of  the  work  on  "Tumors,"  published  in  three  volumes 
in  1863. 

The  first  scientific  work  on  tumors.  Based  on  a  histogenetic  classi- 
fication, it  includes  an  exhaustive  analysis  of  the  older  and  even  oldest 
literature,  and  an  almost  incredible  investigation  of  actual  specimens, 
macro-  and  microscopically.  While  some  of  the  views  have  been 
shown  by  later  methods  to  be  erroneous,  the  work  still  includes  many 
statements  that  reappear  even  now  as  new  discoveries.  It  marked  an 
epoch  and  will  long  be  used  as  a  work  of  reference  for  all  points  not 
requiring  recent  technical  methods  for,,  their  elucidation. 

Senac,  Jean  B.     1693-1770. 

"Traite  de  la  Structure  du  Coeur,  de  son  Action,  et  cetera,"  1749. 

One  of  the  most  important  landmarks  in  the  history  of  diseases  of 
the  heart;  especially  valuable  for  pathologic  anatomy  and  symptoma- 
tology. Senac  was  one  of  the  most  distinguished  French  physicians  of 
the  eighteenth  century. 

AUENBRUGGER,  LEOPOLD.       I722-1809. 

First  edition  of  the  "Inventum  novum,"  1761,  the  first  work  on 
"Percussion." 

BicHAT,  Xavier.     1771-1802. 

The  first  edition  of  the  celebrated  "Anatomie  generale,"  in  which 
histology,  normal  as  well  as  pathologic,  was  first  systematically  studied. 
As  Corvisart  wrote  to  Napoleon,  announcing  Bichat's  death — "No  one 
before  him  has  done  so  much  and  all  so  well  and  perfectly,  in  so  short  a 
time." 

Corvisart,  J.  N.     1755-1821. 

Commentaries  and  Translation  of  Auenbrugger's  work  on  "Per- 
cussion." The  first  edition  was  printed  in  1808.  It  saved  Auenbrug- 
ger  from  oblivion  and  forced  his  work  on  the  attention  of  men  before 
auscultation  was  discovered. 

"Diseases  of  the  Heart,"  1806.  An  important  book,  but  less  so 
than  if  Corvisart  had  written  it  himself.-  It  was  made  up  from  his  lec- 
tures. This,  with  his  "Commentaries  on  Auenbrugger"  would  have 
immortalized  him  had  he  done  nothing  else.  He  was  the  first  of  the, 
modern  physicians ;  founder  of  the  brilliant  French  school  in  the  early 
part  of  the  nineteenth  century;  first  professor  of  medicine  in  the 
Medical  Clinic  in  Paris,  1795 ;  one  of  the  founders  of  modem  patho- 
logic anatomy ;  physician  to  Napoleon. 

Laennec,  Rene-Theophile-Hippolyte.     1781-1826. 

First  edition  of  the  "Mediate  Auscultation." 

In  this  Laennec  followed  an  analytic  method,  describing  in  connec- 
tion with  each  sign  the  anatomic  lesion  indicated.  It  is  the  outcome 
of  "one  of  the  purest  and  most  individual  discoveries  ever  made  in  the 
history  of  science." — (Benjamin  Ward  Richardson.) 

Laennec. 

Second  edition,  the  final  one  by  his  own  hands.  In  this,  an  entirely 
new  work,  he  followed  a  synthetic  method,  with  descriptions  of  disease 


MEDICAL  CLASSICS.  183 

that  proved  the  vast  industry  and  talent  of  the  author.  It  is  a  book  of 
pathol(^y,  as  well  as  diagnosis,  a  complete  treatise  on  diseases  of  the 
heart  and  lungs,  useful  even  at  the  present  day.  Even  the  treatment, 
the  weakest  part,  is  far  in  advance  of  its  time. 

Laennec. 

Showing  the  author's  account  of  the  discovery  of  mediate  auscul- 
tation.    (Ramadge's  English  edition.) 

PiORRY,  P.  A.     1794-1879. 

First  edition  (1828)  of  Piorry's  work  on  "Mediate  Percussion,"  in 
which  the  first  advance  was  made  in  that  art  since  the  time  of  Auen- 
brugger,  namely,  the  use  of  the  pleximeter.  In  this,  and  still  more  in 
later  works,  Piorry  was  led  astray  by  a  search  for  refinements  in  exact 
percussion  that  were  only  slowly  overcome  by  the  work  of  Skoda. 

Skoda,  Joseph.     1805-1881. 

First  edition  (1839)  of  the  "Abhandlung  ucber  Perkussion  und 
Auskultation." 

In  this  epoch-making  work  Skoda  turned  from  the  ultraexact 
methods  of  the  French,  who  aimed  at  discovering  specific  signs  for  each 
disease,  and  laid  the  foundation  of  modern  physical  diagnosis,  in  which 
signs  indicate  physical  conditions,  which  must  be  interpreted  by  the 
revelations  of  pathologic  anatomy.  Like  Auenbrugger,  Skoda  was 
long  neglected  by  his  fellow-countrymen.  The  copy  shown  was  bought 
uncut.  Later,  many  editions  were  published,  some  of  them  large  ones, 
and  translations  in  several  languages. 

Louis,  P.  C.  A.     1787-1872. 

The  first  edition  (1825)  of  the  great  work  on  "Phthisis."  An 
unsurpassed  masterpiece,  said  to  be  "the  most  profound  exposition  of 
the  natural'history  of  a  chronic  disease  of  which  the  literature  of  any 
age  or  country  can  boast."  The  first  work  on  tuberculosis  in  which 
the  whole  condition  of  the  patient  was  thoroughly  examined;  before 
that  many  organs  and  functions  in  the  tuberculous  were  never  studied. 

Gerhard,  William  W.     1809-1872. 

"Lectures  on  Diseases  of  the  Chest."     1842. 

Gerhard  was  a  pupil  of  Louis,  and  was  considered  the  most  distin- 
guished American  who  studied  in  Paris  between  1830  and  1840.  The 
first  who  distinguished  clearly  between  typhoid  and  typhus  fevers 
(article  published  in  The  American  Journal  of  the  Medical  Sciences, 
1835).  The  book  shown  is  his  principal  work.  Diseases  of  the  lungs 
and  the  pericardium  are  especially  well  done.  The  treatment  of  pneu- 
monia is  the  old-fashioned  one — ^bleeding,  tartar  emetic,  et  cetera. 

BowDiTCH,  Henry  I.     1808-1892. 

The  "Young  Stethoscopist"  (1846)  is  a  fine  example  of  the  work 
done  by  the  American  pupils  of  Louis. 

Jenner,  Edward.     1749-1823. 

The  second  edition  of  the  "Inquiry"  into  the  causes  and  effects  of 
the  Variolae  Vaccinae  (1800),  an  exact  reprint  of  the  first  or  1798 
edition. 


184  EDITORIAL  COMMENT. 

"No  book  SO  small  has  ever  been  talked  about  so  much ;  no  book  has 
been  read  from  the  original  so  little;  no  book  of  such  dimensions  has 
made  the  name  of  any  author  so  famous ;  no  book  has  been  so  much 
praised  at  second  hand."  Jenner  transformed  a  local  into  a  universal 
belief. 

Latin  translation  of  Jenner's  first  three  works  into  Latin,  made  by 
Aloisius  Careno,  published  in  Vienna  in  1799.  An  important  factor 
in  the  dissemination  of  a  knowledge  of  Jenner's  discovery. 

Waterhouse,  Benjamin.     1754- 1846. 

"A  Prospect  of  Exterminating  the  Smallpox,"  1802. 

Professor  of  Medicine  in  the  Cambridge  (afterwards,  Harvard) 
Medical  School.  Introduced  vaccination  (1800)  into  the  United 
States,  assisted  its  use  by  his  writings  and  by  enlisting  the  interest  of 
President  Jefferson.  Was  called  the  "J^^i^^r  <^f  the  New  World." 
The  copy  of  his  book  shown  was  given  to  the  father  of  Oliver  Wendell 
Holmes  by  Waterhouse,  and  later  belonged  to  the  Autocrat.  It  bears 
his  book-plate. 

Thomson,  John.     1765-1846. 

In  this  "Account  of  the  Varioloid  Epidemic,"  published  in  1820,  the 
author,  considered  the  most  learned  physician  in  Scotland,  demon- 
strated the  identity  of  smallpox  and  varioloid,  and  showed  that  the 
latter  could  occur  in  those  who  had  had  smallpox,  or  had  been  vacci- 
nated, as  well  as  in  those  who  had  never  passed  through  the  other  dis- 
eases. He  showed  the  unity  of  several  varieties  of  variolous  disease, 
and  thought  that  chickenpox  also  was  merely  a  variety  of  smallpox. 

Carey,  Mathevv.     1760- 1839. 

"Account  of  the  Malignant  [Yellow]  Fever,"  in  Philadelphia.  A 
classic  of  the  first  rank.  It  was  written  in  two  weeks  and  went  through 
four  editions:  November  13,  November  23,  November  30,  1793,  and 
January  16,  1794.  Almost  equal  to  DeFoe's  account  of  the  plague  in 
London,  but  Carey's  work  was  written  in  the  same  season,  while 
DeFoe's  was  composed  long  after  the  plague,  of  which  he  saw  little 
or  nothing. 

Webster,  Noah.     1758-1843. 

"A  Collection  of  Papers  on  the  Subject  of  Bilious  Fevers,  et  cetera." 

The  lexicographer  got  out  this  collection  of  reports  by  physicians, 
with  comments,  in  1896,  before  his  more  celebrated  work  on  "Epidemic 
Diseases."  It  is  chiefly  interesting  now  in  the  light  it  throws  on  the 
manners  and  customs  of  the  time. 

Drake,  Daniel.     1785-1852. 

Equally  eminent  as  patriot,  philanthropist  and  medical  author. 
The  book  on  "Diseases  of  the  Mississippi  Valley"  is  unrivalled  in  the 
amount  and  variety  of  its  material,  and  is  equally  remarkable  for  the 
charm  of  its  style,  the  volume  of  information  on  diseases  and  their 
treatment  in  a  time  and  place  unique  in  the  history  of  the  world,  and 
the  glimpses  of  a  civilization  that  must  always  be  interesting  to 
Americans.     The  Committee  on  Medical  Literature  of  the  American 


► 


r 


MEDICAL  CLASSICS.  186 

Medical  Association,  in  1850,  predicted  that  it  would  probably  come  to 
be  regarded  as  the  most  valuable  original  work  yet  published  in 
America. 

Blackall,  John.     1771-1860. 

In  his  "Observations  on  the  Nature  and  Cure  of  Dropsies,"  first 
published  in  London  (1813),  Blackall  showed  the  association  of  dropsy 
with  albuminuria,  the  most  important  contribution  to  renal  pathology 
before  the  work  of  Bright.  (Albumin  had  been  discovered  in  urine, 
in  1750,  by  Cotunius.) 

Bright,  Richard.     1789- 1858. 

In  this  volume  of  his  "Reports  of  Medical  Cases"  (1827)  Bright 
showed  that  in  some  cases  of  dropsy  with  albuminuria  a  peculiar  alter- 
ation of  the  kidney  was  present.  Next  to  Laennec's  discoveries  in 
thoracic  disease  this  was  perhaps  the  most  important .  discovery  made 
in  medicine  in  the  first  half  of  the  nineteenth  century.  Before  Bright's 
time  examination  of  the  kidneys  was  not  regularly  made  at  autopsies. 

Beaumont,  William.     November  21,  1785 — ^April  25,  1853. 

The  first  edition  of  the  great  work  on  "Experiments  and  Observa- 
tions on  the  Gastric  Juice  and  the  Physiology  of  Digestion,"  Pittsburgh, 
1833.  Open  to  show  one  of  the  illustrations  of  the  opening  into  the 
stomach  of  Alexis  Saint  Martin. 

Danielssen,  D.  C.  and  Boeck,  W. 

"Traite  de  la  Spedalskhed  ou  Elephantiasis  des  Grecs,"  1848. 

The  accurate  scientific  knowledge  of  leprosy  began  with  this  cele- 
brated work  published  at  the  expense  of  the  Norwegian  government 
and  based  on  examinations  of  leper  foci  in  all  parts  of  Europe  at  a 
time  when  many  famous  physicians  believed  leprosy  to  be  extinct. 

HuxHAM^  John.     1692-1768. 

A  translation  of  the  Latin  edition  of  1752,  published  in  1758  or 
1759,  of  the  "Observations  on  Air  and  Epedemic  Disease."  Open  at 
the  celebrated  account  of  "Slow  Nervous  Fever,"  one  of  the  earliest 
recognizable  descriptions  of  typhoid.  He  was  the  inventor  of  Hux- 
ham's  Tincture  of  Cinchona  (Comp.) 

Petit  and  Serres. 

In  the  "Traite  de  la  Fievre  Entero-mesenterique"  (1813),  Petit 
and  Serres  showed  the  constant  presence  of  characteristic  lesions  in  the 
lower  part  of  the  ileum  and  in  the  mesenteric  glands;  described  the 
course  of  the  lesions ;  asserted  they  were  the  cause  and  not  the  effect 
of  the  fever  and  that  the  process  was  due  to  the  introduction  of  a  for- 
eign material. 

Louis'  work  on  "Typhoid  Fever." 

The  second  (1841)  edition,  in  which  the  final  touches  were  given  to 
the  determination  of  typhoid  fever,  the  work  of  the  American  pupils  of 
Louis  being  acknowledged. 

Smith,  Nathan.     1762-1830. 

Founder  and  for  many  years  faculty  (sic!)  of  Dartmouth  Medical 
College ;  Professor  of  Medicine  at  Yale. 


186  EDITORIAL  COMMENT. 

His  "Essay  on  Typhous  Fever"  is  "like  a  fresh  breeze  from  the  sea 
amid  the  dreary  writing  of  most  of  his  contemporaries.  Never  before 
had  the  symptoms  of  typhoid  fever  been  so  clearly  and  accurately  pic- 
tured."—(Welch).  "It  does  not  follow,"  says  the  author,  "that  a 
patient  should  take  medicine  because  he  has  the  disease." 

Bartlett,  Elisha.     1804-1855. 

"History,  Diagnosis,  and  Treatment  of  Typhoid  and  Typhus 
Fever,"  1842. 

"One  of  the  most  notable  of  contributions  of  American  physicians 
to  the  subject.  *  *  *  written  with  great  clearness,  in  logical  order, 
he  shows  in  every  page  an  accurate  acquaintance  with  .the  literature  of 
the  day,  and  a  knowledge  also  of  that  best  of  books,  the  book  of  nature. 
*     *     *     One  of  the  most  successful  medical  works  issued." — (Osier) . 

Macculloch,  John.     1773-1835. 

Physician,  geologist,  et  cetera.  American  reprint  of  the  "Essay 
on  Malaria,"  first  published  in  1827. 

In  this  work  the  term  malaria  was  first  introduced  into  medical  lit- 
erature, and  both  its  use  and  abuse,  the  latter  not  yet  extinct  as  a  cover 
for  diagnostic  ignorance,  began  then.  The  word  had  long  been  in 
popular  use  in  Italy,  and  was  occasionally  applied  by  nonmedical 
English  writers  before  Macculloch,  as:  Horace  Walpole,  1740;  Char- 
lotte Smith,  1801 ;  J.  Forsyth,  1813;  Byron,  1821. 

CuRRiE,  James.     1756-1805. 

Copy  of  the  "Medical  Reports  on  the  Effects  of  Water,"  first  pub- 
lished in  1797.  Currie  sought  to  establish  three  rules  of  practice  in 
the  treatment  of  fevers :  ( i )  In  the  early  stages  cold  water  should  be 
poured  over  the  body.  (2)  In  the  later  stages  the  patient  should  be 
bathed  in  tepid  water.  (3)  In  all  stages  abundant  potations  of  cold 
water  were  recommended.  This  was  the  first  large  series  of  medical 
observations  in  which  clinical  thermometry  was  systematically  used. 

WUNDERLICH,  C.  A.       1815-1877. 

"Das  Verhalten  der  Eigenwarme  in  Krankheiten."  (Second  edition, 
1870). 

The  first  systematic  study  of  clinical  thermometry.  Little  has  been 
added  to  it  and  still  less  changed.  Scattered  observations  on  body 
temperature  were  made  from  the  time  of  Sanctorius  (died  1636), 
especially  by  Boerhaave,  de  Haen  (who  showed  that  the  temperature 
is  elevated  in  the  cold  stage  of  fevers,  and  in  chills),  John  Hunter, 
James  Currie  and  by  others.  Wunderlich  was  the  first  to  get  accurate 
and  frequent  readings  of  the  temperature,  and  the  book  is  based  on 
the  study  of  twenty-five  thousand  cases  and  many  millions  of  single 
observations. 

Brand,  Ernst. 

"Die  Wasserbehandlung  der  typhoesen  Fieber." 

The  second  (1877)  edition  of  the  work  that  led  to  the  modem 
treatment  of  typhoid  fever  by  the  cold  bath. 


ANESTHESIA  BY  SCOFOLAMIN-MORPHIN  187 

ANNOTATIONS. 


A  DISCOVERY   REGARDING  DEAD  TUBERCLE   BACILLI. 

The  experiments  of  Calmette  and  Breton  with  tubercle  bacilli  killed 
by  heat  demonstrate  that  repeated  ingestion  of  the  organisms  hastens 
the  death  of  tuberculous  subjects  in  similar  manner  as  does  the  con- 
tinuous employment  of  minute  doses  of  tuberculin.  The  discovery  is  a 
powerful  argument  against  the  use  of  milk  obtained  from  animals 
which  manifest  even  the  remotest  tendency  toward  tuberculosis.  While 
the  results  of  ingestion  of  dead  tuberculous  material  are  more  delete- 
rious to  consumptives,  normal  persons  are  by  no  means  immune  to  its 
action.  The  authors  conclude  that  under  no  circumstances  should  the 
milk  of  tuberculous  animals,  even  though  sterilized,  be  consumed  by 
persons  afflicted  with  consumption. 


THE  CATASTROPHE  ON  THE  COAST.     * 

On  the  morning  of  April  i8,  San  Francisco  was  visited  by  a 
frightful  disaster  which  laid  the  beautiful  city  in  ruins  and  rendered 
thousands  of  people  destitute  and  homeless.  Possibly  no  siesmic  dis- 
turbance ever  wreaked  such  complete  distruction  on  the  Western 
Hemisphere,  and,  although  the  list  of  dead,  which  is  comparatively 
small,  has  probably  been  overestimated,  the  bodily  ills  which  are 
destined  to  result  from  earthquake  and  holocaust  will  doubtless  visit 
a  large  proportion  of  the  population,  while  the  number  of  fatalities 
indirectly  attributable  to  the  catastrophe  cannot  be  predicted.  Many 
women  endured  the  ordeal  of  childbirth  unassisted  by  medical  attend- 
ance, and  scores  of  premature  births,  precipitated  by  fright  and  expos- 
ure, are  reported.  Physicians,  hampered  by  entire  loss  of  medical 
equipment,  labored  heroically  to  aid  suffering  humanity,  but  with  the 
dearth  of  food  and  clothing,  their  efforts  were  almost  futile,  and 
undoubtedly  many  perished  before  a  food  supply  could  be  established. 
The  country  has  responded  grandly  to  the  calls  for  monetary  assist- 
ance— a  sum  of  magnitudinous  proportions  having  already  been  con- 
tributed, and  if  the  rise  of  other  devastated  cities  may  be  taken  as  a 
criterion  San  Francisco  will  shortly  regain  its  condition  of  hygienic 
and  esthetic  equilibrium. 


SURGICAL  ANESTHESIA   BY   SCOPOLAMIN-MORPHIN. 

While  the  results  obtained  in  the  domain  of  anesthesia  have  been 
varied,  the  operator  has  demonstrated  wonderful  achievements  with 
the  agents  at  present  utilized  to  produce  insensibility.  However,  the 
success  of  surgeons  who  have  tested  scopolamin-morphin  anesthesia, 
the  ease  of  its  administration,  and  the  cheapness  of  the  products 


188  MEDICAL  NEWS. 

bespeak  the  possible  substitution  of  this  anesthetic  for  chloroform 
and  ether  in  the  majority  of  operative  cases.  Scopolamin  is  obtained 
from  Scapolia  Japonica  by  extraction,  having  been  first  isolated  by 
Schmidt  in  1890,  and  first  used  to  produce  anesthesia  by  Schneiderlin 
about  five  years  ago.  The  combination  is  employed  by  hypodermically 
injecting  one-sixty- fourth  of  a  grain  of  scopolamin  hydrobrcmiate  and 
one-sixth  of  a  grain  of  morphin  sulphate  in  fifteen  minims  of  distilled 
water,  four  hours,  two  hours,  and  one  hour  before  commencing  the 
operation.  Following  the  initial  injection  drowsiness  ensues,  and  the 
second  injection  produces  quite  profound  sleep.  A  third  injection  is 
sufficient  to  effect  complete  anesthesia  for  several  hours,  during  which 
time  the  face  is  considerably  flushed,  the  pulse  slightly  accelerated, 
respiration  slow,  and  the  skin  dry  and  warm.  While  the  subject  may 
be  aroused  by  loud  talking  or  shaking,  there  is,  during  the  period  of 
wakefulness, -absolute  insensibility  to  pain.  In  obstetric  practice  this 
anesthetic  is  pronounced  free  from  danger  to  either  mother  or  child 
and  there  is  no  report  of  interference  with  contractions  or  modification 
of  hemorrhage.  The  placidity  with  which  the  injection  is  tolerated 
and  its  freedom  from  symptoms  of  vomiting,  as  well  as  thirst,  together 
with  other  advantages  already  mentioned,  render  the  medicament  a 
possible  succedaneum  to  prevalent  means  for  effecting  anesthesia. 


MEDICAL  NEWS. 


ANN  ARBOR  MEETING  OF  NURSES'  ASSOCIATION. 

The  Michigan  State  Nurses'  Association  held  its  second  annual 
meeting  in  Sarah  Caswell  Angell  Hall,  April  4,  5  and  6,  1906.  James 
B.  Angell,  LL.  D.,  president  of  the  University  of  Michigan,  delivered 
the  address  of  welcome,  and  Doctor  Beverly  D,  Harison,  secretary  of 
the  Michigan  State  Board  of  Registration  in  Medicine,  discoursed  on 
the  "State  Registration  of  Nurses."  Doctor  Victor  C.  Vaughan,  dean 
of  the  medical  department  of  the  University,  contributed  a  paper  on 
"Tuberculosis,"  while  "A  Neglected  Field  of  Nursing — the  County 
Almshouse,"  received  attention  from  Mrs.  Caroline  Bartlett  Crane. 
Doctor  C.  B.  G.  de  Nancrede,  professor  of  Surgery  in  the  University, 
contributed  a  clinic  at  the  hospital,  which  was  well  attended  by  the 
nurses.  The  social  feature  of  the  meeting  contemplated  a  compli- 
mentary concert  tendered  by  the  faculty  of  the  University  School  of 
Music,  under  the  direction  of  Professor  Albert  A.  Stanley,  and  a 
reception  in  Barbour  Gymnasium  given  by  the  graduate  nurses  of  Ann 
Arbor.  The  meeting  was  pronounced  a  profitable  and  pleasureable 
affair.  The  following  officers  were  elected  for  the  ensuing  year: 
President,  Miss  Sarah  E.  Sly,  Birmingham;  first  vicepresident,  Mrs. 
L.  E.  Gretter,  Harper  Hospital,  Detroit;  second  vicepresident.  Miss 


THE  DEMISE  OF  DOCTOR  DOREMUS.  189 

E.  L.  Parker,  State  School  for  the  Blind,  Lansing;  treasurer.  Miss 
Anna  M.  Coleman,  Saginaw  General  Hpspital,  Saginaw;  recording 
secretary,  Miss  Agnes  Deans,  Detroit;  corresponding  secretary,  Miss 
Katherine  Gifford,  Grand  Rapids. 


THE  DEMISE  OF  DOCTOR  DOREMUS. 

Robert  Ogden  Doremus^  A.  M.,  M.  D.,  LL.  D.,  of  New  York, 
died  on  March  22,  1906.  Gotham  was  his  native  city,  and  at  the  corner 
of  Broadway  and  Cortlandt  street  he  first  saw  light  in  1842.  His  father 
was  one  of  the  founders  of  the  University  of  the  City  of  New  York,  and 
from  that  institution  the  son  was  graduated  both  in  arts  and  medicine. 
He  began  his  medical  career  as  assistant  to  Doctor  John  W.  Draper  in  the 
Chemical  Laboratory  of  the  University  Medical  School.  Later  he  spent 
considerable  time  studying  chemistry  and  electrometallurgy  in  Paris.  In 
1848  he  was  appointed  professor  of  chemistry  in  the  New  York  College 
of  Pharmacy,  the  laboratory  of  which  institution  he  equipped  con- 
jointly with  Charles  Townsend  Harris.  Doctor  Doremus  was  one  of 
the  founders  of  the  New  York  Medical  College,  of  the  Long  Island 
College  Hospital,  and  of  Bellevue  Hospital  Medical  College,  in  all  of 
which  he  filled  the  chair  of  chemistry.  From  1853  to  1861  he  was  pro- 
fessor of  natural  history  at  the  Free  Academy  (now  the  College  of  the 
City  of  New  York),  and  later  was  appointed  to  the  chair  of  chemistry 
and  physics  in  the  same  institution.  Through  his  endeavor  the  labora- 
tory at  Twenty-third  street  and  Lexington  avenue  became  a  noted 
center  of  study,  particularly  with  regard  to  electricity.  He  was  the 
first  toxicologic  expert  to  be  called  in  a  murder  case  in  New  York — the 
trial  of  James  Stephens  for  poisoning  his  wife,  and  his  services  led  to 
improvements  in  the  conduct  of  autopsies  for  the  courts.  For  many 
years  he  was  a  well-known  expert  in  criminal  cases,  and  he  is  num- 
bered among  the  first  of  the  presidents  of  the  Medicolegal  Society.  He 
was  a  member  of  the  New  York  Medical  Advisory  Board,  and  assisted 
in  the  organization  of  the  Municipal  Department  of  Health,  and  the 
establishment  of  the  Bureau  of  Chemistry  conducted  in  connection 
therewith.  In  1871  he  was  appointed  president  of  a  board  for  the 
examination  of  druggists  for  licenses  to  practice  pharmacy.'  He  inaugu- 
rated the  chlorine  system  of  disinfecting  ships,  and  thus  obviated  the 
necessity  for  prolonged  detentions  at  quarantine.  The  important  inven- 
tion of  granulated,  compressed  gunpowder  contemplates  another  of 
his  achievements.  This  product  was  employed  by  the  French  in  the 
Franco-Prussian  War,  its  power  greatly  exceeding  that  of  ordinary 
gunpowder.  The  excavation  of  Mont  Cenis  tunnel  was  also  wrought 
by.  this  product.  Doctor  Doremus  was  interested  in  every  department 
of  culture,  and  was  especially  prominent  in  musical  circles,  being  one 
of  the  founders  of  the  Philharmonic  Society,  of  which  he  likewise 
officiated  as  president  for  some  time.  Several  years  ago  he  celebrated 
his  golden  wedding,  but  since  then  his  wife  has  died,  and  four  children 
survive  him,  Professor  Charles  A.  Doremus  being  the  oldest. 


190  MEDICAL  NEWS. 

MINOR  INTELLIGENCE. 

An  epidemic  of  smallpox  is  threatened  in  the  penitentiary  located 
at  Lansing,  Kansas,  four  convicts  having  recently  been  stricken  with 
the  disease. 

The  establishment  of  a  state  tuberculosis  sanatorium  in  Iowa  has 
been  facilitated  by  the  passage  of  a  bill  in  the  legislature  appropriating 
$50,000  for  the  purpose. 

At  the  recent  Pittsburg  meeting  of  the  American  Association  of 
Medical  Colleges,  the  medical  department  of  Oklahoma  University 
was  admitted  to  membership. 

Typhoid  fever  is  epidemic  in  Pittsburg,  more  than  four  hundred 
cases  having  thus  far  been  admitted  to  the  hospitals,  besides  the  hun- 
dreds of  other  cases  scattered  throughout  the  city. 

The  sum  of  $50,000  has  been  provided  by  Mrs.  Louisa  N.  BuUard 
for  the  establishment  of  a  Chair  of  Neuropathology  at  Harvard 
University.  The  bequest  is  made  as  a  memorial  to  the  husband  of 
the  donor,  William  Story  Bullard. 

Saint  Luke's  Hospital,  New  York,  has  been  enriched  to  the 
extent  of  $15,000  by  a  bequest  of  Mrs.  Sarah  A.  Sands,  whose  death 
occurred  recently.  The  sum  will  be  utilized  to  endow  three  beds  in 
memory  of  the  donor's  husband,  Abraham  B.  Sands. 

The  Prussian  Minister  of  Railways  has  inaugurated  a  novelty  in 
the  method  of  transporting  sick  persons  in  railway  coaches.  Suitable 
stretchers  will  be  admitted  to  third-class  compartments,  two  third-class 
fares  being  paid  for  patient  and  stretcher  and  one  for  the  attendant. 

Experiments  announced  from  the  Edinburgh  University  research 
laboratory  are  to  the  effect  that  trypsin  injected  into  a  cancerous  mass 
will  effect  its  absorption,  but  since  the  agent  has  only  been  employed 
on  rodents,  its  practical  value  in  human  subjects  remains  undetermined. 

Doctor  Johann  Flintermann  was  recently  tendered  a  testimonial 
dinner  by  the  Detroit  Club  in  commemoration  of  the  fortieth  anniver- 
sary of  his  advent  into  medical  practice.  Doctor  Flintermann  received 
his  medical  degree  from  the  University  of  Gottingen  in  1864,  and  two 
years  later  he  located  in  Detroit. 

A  FREE  tuberculosis  clinic,  to  be  in  charge  of  Doctor  Victor  C. 
Vaughan,  was  recently  opened  in  the  Detroit  Board  of  Health  building. 
It  is  estimated  'that  there  is  an  average  of  one  death  a  day  in  Detroit 
from  this  disease,  and  the  purpose  of  the  clinic  is  to  instruct  subjects 
how  to  care  for  themselves  and  prevent  the  spread  of  contagion. 

Doctor  Frank  William  Smithies  has  been  appointed  demon- 
strator of  medicine  in  the  University  of  Michigan,  to  succeed  Doctor 
Roger  S.  Morris,  who  accepted  a  position  in  Johns  Hopkins  Hospital. 
Doctor  Smithies  is  an  Ann  Arbor  graduate,  and  since  receiving  his 
degree  has  been  connected  in  a  teaching  capacity  with  the  University 
of  Chicago. 


EPITOME  OF  THE  PRACTICE  OF  MEDICINE.  191 

Fourteen  women  physicians  of  Detroit  recently  organized  a  society 
whose  membership  is  limited  exclusively  to  women  practitioners.  It 
is  designated  the  Women's  Academy  of  Medicine,  and  is  the  third  of 
its  kind  in  the  country,  the  others  being  located  at  New  York  City  and 
Rochester,  New  York.  Women  physicians  in  Michigan  who  are  mem- 
bers of  their  county  society  are  eligible  to  membership  in  the  new 
guild.  The  following  officers  were  elected  for  the  ensuing  year: 
President,  Doctor  Lucy  J.  Utter;  vicepresident.  Doctor  Mary  G. 
Haskins;  secretary.  Doctor  Anna  Starring;  treasurer.  Doctor  Minta 
P.  Kemp;  councilors,  Doctors  Florence  Huson,  Louise  Rosenthal- 
Thompson  and  Isabella  Holdom. 

On  April  2  a  free  clinic,  to  be  known  as  the  German  Polyclinic, 
was  established  in  connection  with  Grace  Hospital,  Detroit.  The  new 
institution  will  be  essentially  German  in  character,  none  but  physicians 
of  Teutonic  extraction  being  eligible  for  official  positions,  although 
treatment  will  be  tendered  to  afflicted  regardless  of  race  or  creed. 
Doctors  Herman  Kiefer  and  Ernest  W.  Haas  have  been  elevated 
respectively  to  the  presidency  and  secretaryship,  and  the  various  chairs 
will  be  occupied  as  follows:  Children's  diseases,  Doctors  Charles  G. 
Jennings  and  Guy  L.  Kiefer ;  general  medicine :  attending  staff.  Doctors 
Ernest  W.  Haas  and  August  Gorenflo;  consulting  staff,  Doctors  Carl 
Bonning  and  Herman  Kiefer;  diseases  of  the  eye  and  ear,  Doctor 
Louis  J.  Hirschman ;  diseases  of  women.  Doctor  James  A.  MacMillan ; 
nose  and  throat,  Doctor  Fred  J.  Clippert;  diseases  of  the  digestive 
organs.  Doctor  George  W.  Wagner;  pathologist,  Doctor  Edward  H. 
Hay  ward;  surgery.  Doctors  Johnston  B.  Kennedy  and  George  H. 
Palmerlee. 


RECENT  LITERATURE- 


REVIEWS. 


EPITOME  OF  THE  PRACTICE  OF  MEDICINE.* 
This  little  manual  is  indeed  an  excellent  guide  so  far  as  it  goes.  It 
is  intended  to  be  only  an  epitome.  There  are  men  who  oppose  the  use  of 
these  contractions — good  men;  and  there  are  men  who  think  they  are 
of  great  use  to  the  student  and  practitioner  who  are  also  good  men. 
These  compendiums  cannot  help  being  good  books  because  they  are 
copied  from  good  books.  Usually  they  are  condensed  rearrangements 
of  Osier's,  Anders',  or  some  other  standard  work,  altered  just  enough 
to  make  the  reading  a  little  different,  with  the  definitions  a  bit  modified. 
Even  those  who  oppose  them  enjoy  perusing  them.  They  are  some- 
times refreshing,  and  if  one  should  question  closely  he  will  probably 


192  RECENT  LITERATURE. 

find  that  these  men  are  fond  of  some  similar  little  book,  the  only  differ- 
ence being  that  it  is  published  in  another  language.  We  find  a  few 
mistakes  but  they  can  easily  be  excused  on  the  ground  of  "first  edition." 
We  think  that  many  of  these  abbreviated  books  have  a  place,  and  many 
of  them  fill  a  long  felt  want.  This  is  one  of  them.  Jt  is  thoroughly 
up-to-date. 

*A  Manual  for  Students  and  Practitioners.  By  Hughes  Dayton, 
M.  D.,  Principal  to  the  Class  in  Medicine,  New  York  Hospital,  Out- 
Patient  Department;  Clinical  Assistant  in  Medicine,  Vanderbilt  Clinic, 
College  of  Physicians  and  Surgeons,  Columbia  University.  In  one 
i2mo  volume  of  324  pages.  Cloth,  $1.00,  net.  Lea  Brothers  &  Com- 
pany, Publishers,  Philadelphia  and  New  York,  1905. 


A  LABORATORY  MANUAL  OF  PHYSIOLOGICAL 
CHEMISTRY.* 

Doctor  Rockwood's  laboratory  manual  is  admirably  adapted  to  the 
needs  of  the  student  of  physiological  chemistry.  Only  the  most  impor- 
tant illustrative  experiments  are  given  in  large  type  and  they  are  not 
too  many  and  are  well  chosen.  It  has  the  advantage  over  books  that 
are  filled  with  interrogations  in  that  while  it  does  not  fail  to  interrogate, 
it  intelligently  answers,  thus  making  it  of  service  to  the  student  and  of 
inestimable  value  to  the  busy  physician  who  wants  an  immediate  reply 
to  his  query.  Here  and  there  are  additional  leaves  inserted  for  notes. 
Altogether  the  book  is  a  very  valuable  one,  and  can  be  especially  recom- 
mended to  those  who  wish  to  begin  the  study  of,  or  review  the  sub- 
ject. D.   M.  c. 

*By  Elbert  W.  Rockwood,  M.  D.,  Ph.  D.,  Professor  of  Chemistry 
and  Toxicology  and  Head  of  the  Department  of  Chemistry  in  the 
University  of  Iowa,  et  cetera.  Second  edition,  revised  and  enlarged. 
With  one  colored  plate  and  three  plates  of  microscopic  preparations. 
Large  i2mo,  229  pages,  extra  cloth.  Price,  $1.00,  net.  F.  A.  Davis 
Company,  Publishers,  1914  Cherry  street,  Philadelphia,  Pennsylvania. 


PROGRESSIVE  MEDICINE. 

Progressive  Medicine  for  December  is  full  of  its  usual  amount  of 
the  world's  best  medical  literature.  We  have  praised  the  merits  of 
this  publication  so  many  times  that  it  seems  unnecessary  to  say  more. 
It  is  one  of  our  most  welcome  visitors.  It  is  impossible  to  see  how  it 
could  be  improved.  d.  m.  c. 

*A  Quarterly  Digest  of  Advances,  Discoveries,  and  Improvements 
in  the  Medical  and  Surgical  Sciences.  Edited  by  Hobart  Amory  Hare, 
M.  D.,  Professor  of  Materia  Medica  and  Therapeutics  in  the  Jefferson 
Medical  College  of  Philadelphia.  Lea  Brothers  &  Company,  Pub- 
lishers, Philadelphia  and  New  York. 


A  PROFESSIONAL  MEDICAL  JOURNAL. 


VOLUME  XXVIII.  MAY,  1906.  NUMBER  V. 


ORIGINAL  ARTICLES. 


MEMOIRS. 


MODERN  SKIAGRAPHIC  TECHNIQUE.* 

By  VERNON  J.  WILLEY,  A.  M.,  Ann  Arbor,  Michigan. 

DIRSCTOR  OF  THB  UNIVBRSITT  HOSPITAL  ROSNTGBN  LABORATORY. 

It  is  undoubtedly  true  that  the  technique  employed  in  making 
Roentgen  radiographs  is,  with  many  who  make  use  of  the  Roentgen 
rays  in  diagnosis,  largely  the  result  of  habit  and  convenience.  It  is 
with  most  of  us,  largely  a  personal  problem.  It  is  also  true  that  radiog- 
raphy is  largely  an  art,  and  partakes  but  little  of  systematic  scientific 
application.  Yet  there  are  certain  fundamental  principles,  recognized 
by  many,  which  are  preparing  the  way  for  a  logically  developed  system. 

What  is  meant  by  a  good  radiograph?  What  should  it  show? 
How  shall  we  judge  whether  or  not  it  is  technically  correct?  First  of 
all  it  is  well  to  be  clear  on  one  point :  a  radiograph  is  not  a  photograph. 
It  does  not  represent  by  its  shades  and  shadows,  the  real  object.  It 
is  a  record  of  the  different  densities  encountered  by  the  Roentgen  rays 
in  their  passage  through  a  body  made  up  of  materials  presenting  differ- 
ent degrees  of  obstruction  to  the  passage  of  the  rays.  A  photograph 
is  a  record  of  impressions  made  by  rays  of  light  of  various  degrees  of 
intensity,  reflected  from  the  object  to  the  sensitive  plate.  There  may 
be  no  suggestion  of  the  density  of  the  object  photographed.  The  pho- 
tograph represents  the  real  object,  and  is  easy  of  recognition.  The 
radiograph  is  a  record  of  the  densities  of  the  different  parts  or  organs 
through  which  the  rays  pass  to  reach  the  sensitive  plate,  and  may  or 
may  not  be  easy  of  recognition;  in  not  a  few  instances  it  requires  a 
radiographically  trained  eye  for  its  correct  interpretation.  A  good 
radiograph  is  one  which,  first  of  all,  renders  a  truthful  record  of  these 
densities,  and  is  simple  and  easy  of  interpretation.     Negatives  must 

♦Read  at  the  Ann  Arbor  meeting  of  the  First  Councilor  District  Medical 
Society,  December  22,  1905. 


194  ORIGINAL  ARTICLES. 

be  produced  showing  the  greatest  possible  contrast  between  tissues  of 
different  density.  The  differentiation  must  be  sharp  and  clean  cut,  the 
negative  clear,  clean,  and  free  from  iog  or  haziness.  The  simplest 
method  of  judging  of  the  value  of  the  radiograph  as  to  whether  it  shows 
the  presence  or  absence  of  pathological  conditions,  is,  of  course,  com- 
parison with  a  normal  radiograph.  The  anatomical  structures  which 
show  in  the  normal  radiograph  should  be  carefully  studied  and  com- 
pared with  the  corresponding  structures  of  the  radiograph  in  which 
pathological  structures  may  be  revealed.  Theoretically  one  should  be 
able  to  show  by  a  radiograph  any  pathological  condition  involving  a 
marked  change  in  density  of  the  involved  tissues.  Practically  we  are 
able  to  realize  this  to  a  very  satisfactory  degree,  but  it  is  useless  to 
place  much  reliance  upon  a  skiagraph  which  has  not  truthfully  recorded 
normal  structures  which  differ  more  in  density  than  the  change  from 
normal  to  pathological. 

The  production  of  a  radiograph  fulfilling  the  necessary  conditions 
depends  upon — 

First,  properly  selected  electrical  apparatus  kept  in  perfect  working 
order. 

Second,  properly  selected  and  properly  excited  vacuum  tubes. 

Third,  suitable  accessories  for  diaphragming  the  rays,  and  for 
immobilizing  the  part  radiographed,  and 

Fourth,  reliable  sensitive  plates  or  films,  followed  Ky  correct  and 
special  photographic  technique. 

The  electrical  apparatus,  static  machine,  induction  coil,  or  high 
tension  transformer  should  be  one  with  which  the  operator  is  thor- 
oughly familiar.  If  he  expects  to  progress  further  than  the  elements 
of  the  subject,  embraced  in  the  radiography  of  extremeties,  he  will 
require  an  induction  coil  capable  of  delivering  at  least  a  nine-inch  solid 
flame,  and  preferably  one  delivering  more  than  a  fourteen-inch  flame. 
The  apparatus  must  be  so  adjusted,  and  supplied  with  controlling 
rheostat  and  variable  inductance,  as  to  respond  at  once  to  his  varied 
requirements.  If  he  is  to  attempt  rapid  w^ork,  the  primary  circuit  must 
be  broken  by  an  electrolytic  interrupter  preferably  of  the  Wehnelt  type. 
This  invention  of  Wehnelt  has  done  more  than  any  one  thing  to  make 
possible  the  extensive  use  of  Roentgen  rays  in  diagnosis.  The  Wehnelt 
interrupter  is  simple  of  construction,  works  equally  well  on  alternating 
and  direct  currents,  and  the  operator  who  makes  his  own  and  keeps 
it  in  repair  has  mastered  a  large  percentage  of  the  instrumental  troubles 
which  are  likely  to  confront  him. 

The  fundamental  requisite  of  the  Roentgen  tube  is  that  its  rays 
must  penetrate  the  tissues  to  be  radiographed.  The  thicker  the  tissues 
or  the  greater  the  density  the  greater  must  be  the  penetration.  The 
proper  working  of  the  tube  is  exhibited  by  the  hemisphere  of  the  tube 
in  front  of,  or  anterior  to  the  face  of  the  anode,  fluorescing  brilliantly, 
clearly,  and  steadily.  The  hemisphere  of  the  tube  back  of  the  anode 
should  be  quite  dark,  without  fluorescence,  and  without  irregular  fluor- 


MODERN  SKIAGRAPHIC  TECHNIQUE.  195 

escent  rings.     This  latter  condition  is  important,  even  though  at  times 
difficult  of  accomplishment. 

The  penetration  of  the  tube  is  a  perfectly  measurable  quantity,  and 
its  actual  measurement  is  an  important  advance  in  bringing  about 
improvement  in  and  uniformity  of  methods. 

A  simple  form  of  penetrometer  may  be  made  by  a  combination  of 
the  Renoist  i^enetrometer  and  the  aluminum  window  penetrometer. 
Cylinders  of  aluminum,  of  two,  four,  et  cetera,  to  sixteen  millimeters  in 
thickness,  and  about  eight  millimeters  in  diameter,  are  cut  from  a  rod 
of  aluminum,  and  the  eight  cylinders  set  in  apertures  in  lead,  the  first 
four  in  lead  one-half  millimeter  thick,  and  the  remaining  four,  ten  to 
sixteen  millimeters  thick,  set  in  apertures  of  a  strip  of  lead  one  milli- 
meter thick.  The  device  is  then  glued  to  a  thin  board,  and  placed  in 
front  of  a  small  fluoroscope.  Tubes  whose  rays  penetrate  freely  the 
first  four  or  five  aluminum  cylinders,  and  the  one-half  millimeter  lead 
strip  not  at  all,  are  "soft"  tubes,  or  "low  tension"  tubes,  although  the 
latter  term  is  a  misnomer.  Tubes  whose  rays  penetrate  all  the  cylinders 
and  the  one-half  millimeter  lead  strip  to  some  extent,  are  ''hard"  tubes, 
or  "high  tension"  tubes.  The  terms  hard  and  soft  are  purely  relative, 
having  to  do  only  with  the  penetration  of  the  rays. 

The  Walter  penetrometer  is  the  international  standard.  Soft  tubes 
penetrate  four  or  less  platinum  windows,  while  hard  tubes  penetrate 
from  five  to  seven  windows.  Tubes  are  now  designated  as  Walter 
4.  5.  6  or  7.  according  to  their  penetration. 

Besides  being  of  correct  penetrating  power  the  tube  must  be  capable 
of  enduring  a  heavy  current  (amperage)  for  the  required  time  of 
exposure,  that  is  one-half  second  to  six  or  eight  minutes,  without  over- 
heating, lowering  of  vacuum  and  lessening  in  penetration.  It  should 
be  one  which  emits  a  large  percentage  of  direct  rays,  supposedly  from 
the  focal  point  on  the  anode,  and  a  small  percentage  of  indirect  rays, 
or  rays  from  the  walls  of  the  tube,  or  at  least  not  from  the  focal  point 
on  the  anode.  If  a  hard  tube  be  used,  it  is  preferable  to  use  one  which 
has  been  aged  or  seasoned  to  the  degree  where  it  will  emit  rays  of  a 
nearly  homogeneous  character,  rather  than  a  mixture  of  rays  varying 
from  those  of  extreme  softness  to  those  of  extreme  hardness.  The 
tube  should  be  one  having  a  high  efficiency  as  a  transformer  of  elec- 
trical energy  into  Roentgen  rays. 

At  present  there  is  no  simple  and  satisfactory  method  of  measuring 
directly  the  volume  of  rays  given  off  by  a  Roentgen  tube.  The  nearest 
approach  to  it  is  the  measurement  of  a  function  w^hich  is  proportional 
to  it.  namely,  the  current  exciting  the  tube.  A  milliamperemeter  con- 
structed to  be  used  in  series  with  the  tube  indicates,  for  a  given  tube 
excited  by  the  same  apparatus,  a  current  strength  proportional  to  the 
radiant  output  of  the  tube.  Or  more  strictly  speaking,  the  volume 
of  rays  is  proportional  to  the  square  of  the  current  strength,  provided 
the  resistance  of  the  tube  and  the  penetration  remains  constant.  This 
is  very  nearly  realized  in  practice,  radiographically,  for,  in  exposing  a 


196  ORIGINAL  ARTICLES. 

Structure  for  radiographic  purposes,  if  two  milliamperes  through  the 
tube  requires  an  exposure  of  sixteen  seconds,  four  milliamperes  requires 
not  eight  seconds,  but  only  about  four,  and  a  radiograph  may  be  made 
of  the  part  exposed  in  one  and  one-half  to  two  seconds  if  we  can  excite 
it  by  six  milliamperes.  It  is  possible  to  secure  a  good  radic^raph  of 
a  one  hundred  fifty  pound  man  in  one  second,  by  using  a  Walter  6 
tube,  excited  by  six  milliamperes,  from  an  induction  coil  actuated  by  an 
electrolytic  interrupter. 

With  reference  to  the  penetration  of  tubes  employed  in  radiography, 
Roentgenologists  are  divided  more  or  less  sharply,  into  two  schools, 
advocates  of  soft  tube  technique,  with  attendant  long  exposures,  employ- 
ing Walter  3  to  5  tubes,  and  users  of  hard  tubes,  Walter  5  to  7,  requiring 
exposures  of  one-half  second  to  ten  seconds,  for  radiographing  any 
part  of  the  body,  while  the  Walter  3,  4,  or  5  tube  requires  from  twenty 
seconds  to  six  minutes  exposure  to  do  the  same  work.  So  far  as  I 
know,  there  are  no  radic^raphers  who  are  equally  skilled  in  the  use  of 
both  hard  and  soft  tubes. 

At  first  thought  it  might  seem  that  the  advantages  are  all  with  the 
use  of  the  Walter  5,  6,  and  7  tubes.  This,  however,  is  not  true,  as  soft 
tubes,  Walter  5  or  less,  possess  the  undeniable  advantage  of  giving 
greater  detail  and  contrast  in  soft  parts,  especially  radiography  of  abdo- 
men and  chest,  than  the  average  hard  tube.  In  other  words,  we  are 
able,  by  using  the  soft  tube,  to  record  upon  the  plate  more  marked 
differentiation  between  tissues  differing  but  slightly  in  density.  In 
addition  the  likelihood  of  overexposing  the  plate  is  very  much  less  than 
when  using  the  hard  tube.  On  the  other  hand  there  is  the  greatest 
danger  of  "burning" — it  is  the  rays  of  slight  penetration  which  produce 
changes  in  the  integument. 

The  difficulty  of  immobilizing  the  patient  during  the  long  exposure, 
the  absolute  impossibility  of  radiographing  lungs  and  abdomen  during 
suspended  respiration,  and  the  numerous  failures  in  attempted  radio- 
graphy of  small  children  who  cannot  be  kept  from  moving  during  the 
exposure,  are  drawbacks  which  have  from  time  to  time  annoyed  and 
discouraged  the  user  oi  the  soft  tube.  The  greatest  trouble  of  all, 
however,  is  the  rapid  heating  of  the  soft  tube  under  heavy  current 
excitation,  its  quickly  lowering  vacuum  following  this,  and  the  resulting 
lessening  of  the  penetration  rendering  the  tube  for  the  time  absolutely 
worthless  for  radiographic  purposes. 

With  the  use  of  the  hard  tube  there  is  extreme  improbability  of 
producing  a  dermatitis,  even  if  a  dozen  radiographs  be  taken  of  the 
same  patient,  the  same  day.  It  is  also  possible  to  secure  immobility 
of  all  parts  of  the  body.  One  can  radiograph  either  chest  or  abdomen 
during  suspended  respiration,  and  avoid  all  blurring  of  shadow-detail 
due  to  respiratory  movements.  With  a  properly  seasoned  old  Roentgen 
tube  we  may  pass  a  heavy  current  through  it  for  a  dozen  consecutive 
radiographs  without  materially  interfering  with  its  penetration.  Such 
a  tube  also  possesses  a  higher  efficiency  as  a  transformer  of  electrical 


MODERN  SKIAGRAPHIC  TECHNIQUE.  197 

energy  into  Roentgen  rays.  There  are  some  important  changes  taking 
place  during  the  life  of  a  tube,  which  all  experienced  radiographers  have 
noted.  The  new  tube  is  naturally  soft.  It  produces  really  good  radio- 
graphs only  when  in  this  condition.  Its  vacuum  is  very  unstable.  It 
will  heat  and  run  down  during  exposure,  and  rise  a  little  higher  in 
vacuum  on  cooling.  After  a  time  it  reaches  a  degree  of  hardness 
where  its  rays  freely  penetrate  the  bones.  It  has  reached  a  penetration 
of  Walter  6  or  7,  but  it  possesses  poor  definition;  that  is,  the  output 
of  direct  rays  may  be  as  low  as  twenty  per  cent  of  the  energy  absorbed, 
while  the  indirect  rays  may  be  as  great  as  forty  to  sixty  per  cent,  the 
balance  of  the  energy  being  transformed  into  heat.  Upon  lov^ering 
the  vacuum  successively,  it  will  naturally  run  longer,  without  excessive 
heating,  and  not  rise  as  rapidly  upon  cooling.  It  is  approaching  a  stage 
where  its  vacuum  is  more  nearly  stable.  In  the  course  of  a  year,  if  the 
tube  be  used  for  a  short  time  daily,  it  has  undergone  remarkable 
changes.  The  glass  of  the  anterior  hemisphere  becomes  darkened. 
The  glass  annealed,  the  vacuum  more  constant,  it  will  stand  a  heavy 
current  without  heating,  and  instead  of  fluorescing  a  greenish-yellow 
or  an  olive  green,  it  will  fluoresce  a  sunflower-yellow,  a  yellow  almost 
as  pure  as  the  sodium  light.  Its  penetration  is  about  Walter  6.  It 
gives  beautiful  definition;  the  medullary  canal  of  the  ulna  is  clearly 
defined  by  the  fluoroscope.  It  has  become  a  seasoned  tube.  Its  output 
of  direct  rays  may  rise  as  high  as  seventy  per  cent  of  the  output  of 
radiant  energy,  and  the  rays  seem  to  be  much  more  nearly  homo- 
geneous in  quality  than  those  from  a  Walter  6  new  tube.  Such  a  tube 
is  worth  many  times  the  value  of  a  new  tube  for  radiographic  purposes. 
It  is  better  to  save  a  well  seasoned  old  tube  for  the  more  difficult  work, 
such  as  radiography  of  skull,  chest,  renal  and  biliary  calculi. 

The  use  of  the  diaphragm  for  cutting  off  the  indirect  rays  is  of  the 
greatest  service,  particularly  when  using  a  comparatively  new  hard 
tube.  A  scientifically  constructed  diaphragm,  with  its  accompanying 
compression  cylinder  or  compression  ring  is  a  necessary  accessory  to 
every  fully-equipped  radiographic  armamentarium. 

In  the  construction  of  these  compression  diaphragh  cylinders  some 
deplorable  mistakes  have  been  made  which  appear  to  be  due  to  a  lack 
of  knowledge  of  the  fundamental  principles  of  radiant  energy.  When 
Roentgen  rays  or  any  other  form  of  radiant  energy  pass  from  one 
medium  to  another  of  different  density,  the  particles  of  the  second 
medium  act  as  secondary  centres  for  the  production  of  secondary  radia- 
tions, according  to  the  principle  of  Huygens.  Hence  if  we  would 
avoid  the  secondary  rays  from  the  inside  of  the  cylinder,  we  must 
make  our  diaphragm  at  the  top  of  the  cylinder  the  truncated  portion  of 
a  cone  whose  apex  is  the  focal  point  on  the  anode,  and  whose  base  is 
coincident  with  the  periphery  of  the  bottom  of  the  cylinder.  We  are 
indebted  to  Albers  Shonburg  for  the  compression  diaphragm  cylinder 
and  to  Dessauer  for  first  calling  attention  to  the  correct  principles  of 
construction  of  ^ch  apparatus. 


198 


ORIGINAL  ARTICLtrS. 


It  is  perfectly  possible  to  make  a  radiograph  by  means  of  these 
secondary  .i--rays  generated  from  the  inside  of  the  cylinder  of  improper 
construction.  The  direct  rays  may  be  intercepted  by  a  thick  lead  disc, 
ami  the  secondary  .t--rays,  s  (Figure  I),  allowed  to  pass  through  the 
structure  to  be  radiographed.  On  the  other  hand  their  production  may 
be  eliminated  by  the  proper  diaphragm,  while  at  the  same  time  mini- 
mizing the  transmission  of  indirect  radiations  from  the  tube.  The 
accompanying  diagram  (Figure  I)  illustrates,  in  the  left  hand  half  of  the 
figure,  a  cylinder  of  improper  construction,  with  its  indirect  and  sec- 
ondary rays,  while  the  right  half  shows  how  these  may  be  eliminated 
by  the  diaphragm  of  correct  aperture.  A  diaphragm  apparatus  of  nearly 
universal  application  may  be  constructed  by  covering  a  suitable-sized 


FiGURK  I. — (d)  Apex  of  cone  of  direct  rays,    (i)  Indirect  rays  from  walls  of  tube,    (s)  Sec"^ 
ondary  rays  from  cylinder  walls. 

board  or  fiber  support  with  a  layer  of  a  mixture  of  putty  and  mercurous 
oxide  on  the  side  next  the  tube.  A  convenient  aperture,  of  from  five 
to  eight  centimeters,  is  left  in  the  center.  This  diaphragm,  being  a  non- 
conductor, nonmagnetic,  and  noninductive,  may  be  placed  in  direct 
contact  with  the  tube.  Suitable  lead  diaphragms  may  be  employed  for 
further  limiting  the  field  covered  by  the  rays,  and  two  or  more  rings 
may  be  detached  to  the  under  side  of  the  diaphragm  for  purposes  of 
compression  or  immobilization.  The  diagram  (Figure  II)  will  make 
clear  its  construction. 

The  compression  rings  of  seven  and  one-half  and  ten  inches  in 
diameter,  in  addition  to  a  five  and  one-half  inch  cylinder,  will  fulfill 
about  all  of  the  requirements  demanded  of  such  apparatus  by  the  radiog- 
rapher. 

Lastly,  I  wish  to  mention  briefly  the  photographic  technique.     The 


MODERN  SKIAGRAPllIC  TECHNIQUE. 


109 


radiograph  is  a  special  negative.  It  should  possess  strong  and  emphatic 
contrasts.  Two  of  the  most  important  factors  in  the  production  of  the 
best  grade  of  radiographs  are  the  correct  exposure,  and  the  correct 
developmental  technique.  The  physician  who  exposes  his  plates,  and 
then  passes  them  on  to  a  portrait  or  landscape  photographer  for  devel- 
opment, will  not  obtain  the  highest  grade  of  work,  until  both  learn 
by  experience  the  important  difference  between  a  landscape  or  portrait 
negative,  and  a  radiographic  negative.  A  different  developing  formula 
and  a  different  duration  of  development  are  essential.  Especially  is 
this  true  if  the  hard  tube  technique  be  employed. 

In  conclusion,  I  may  say  that  while  a  great  deal  depends  upon  the 
apparatus  and  its  correct  management,  there  is  also  the  personal  factor 


Figure  II. — (a)  Layer  of  putty   and   mercurous   oxide.      (b)  Wood  or  fiber  support, 
(c)  Metal  diaphragm,     (d)  Cone  of  direct  rays. 

of  the  radiographer.  If  he  would  succeed  he  must  train  his  judgment 
by  keeping  a  careful  record  of  all  exposures,  and  making  careful 
measurements  of  all  the  factors  which  he  employs,  which  are  capable 
of  measurement.  It  is  only  by  persistent  systematic  training  that  he 
can  ever  hope  to  be  able  either  to  duplicate  his  best  results  or  to  place 
his  work  on  a  scientific  basis. 

The  use  of  the  Roentgen  rays  in  diagnosis  has  made  remarkable 
strides  since  the  presentation  of  Roentgen's  paper  upon  its  discovery, 
ten  years  ago  this  month.     If  the  next  five  years  are  as  fruitful  in 


200  ORIGINAL  ARTICLES. 

progress  as  the  last  five,  even  the  skeptics  will  be  compelled  to  admit 
that  this  new  diagnostic  and  therapeutic  agent  is  the  most  useful,  if 
not  the  most  interesting,  contribution  that  the  science  of  Physics  has 
ever  made  to  the  science  of  Medicine. 


A  SURGICAL  PILGRIMAGE  TO  ARKANSAS. 
By  HAL  C.  WYMAN.  M.  S.,  M.  D..  Detroit,  Michigan. 

PROPBSSOIl  or  SURGBKY   IN  THB  MICHIGAN  COLLBGB  OP  MBDICINB  AND  SURGBRY. 

Arkansas  was  settled  originally  by  people  from  Tennessee,  and 
consequently  the  Arkansans  maintain  the  customs  and  trend  of  thought 
common  to  the  Tennesseeans.  In  the  early  days  of  that  state,  there 
was  a  law  to  the  effect  that  if  a  negro  went  about  the  country  prac- 
ticing medicine  or  healing  the  sick,  he  was  punished  by  a  drubbing  not 
to  exceed  twenty-five  lashes,  while  his  master,  if  he  were  cognizant  of 
the  fact,  was  liable  to  a  fine.  The  people  of  Tennessee  would  not  allow 
any  "free"  colored  person  to  remain  in  their  state  more  than  twenty 
days,  and  slaves  were  never  permitted  to  assemble  in  unusual  numbers, 
without  the  expressed  consent  of  their  owners.  In  Arkansas  now 
there  is  a  State  Medical  Society  composed  entirely  of  colored  physi- 
cians. I  met  the  president.  Doctor  Claude  M.  Wade,  during  a  recent 
sojourn  in  Hot  Springs.  I  found  him  a  regular  graduate  in  medicine, 
practicing  his  art  in  accordance  with  the  laws  of  the  state.  He  is  at 
the  head  of  the  Saint  Pythias  Sanitarium  in  that  city,  an  institution 
with  twenty  beds,  which  takes  patients  of  any  color.  The  medical  law 
of  Arkansas  recognizes  all  the  "pathies."  If  a  man  would  practice 
regular  medicine,  be  he  white  or  colored,  he  must  appear  before  a 
board  of  regular  physicians,  exhibit  his  diploma,  and  pass  a  satisfactory 
examination.  If  he  is  an  eclectic,  as  many  of  them  are,  he  is  required 
to  appear  before  a  board  of  that  persuasion,  exhibit  his  diploma,  and 
give  written  evidence  of  qualification  in  order  to  gain  the  right  to 
practice. 

Hot  Springs,  the  mecca  of  many  medical  pilgrims  like  myself,  is 
located  in  Garland  county,  and  after  having  visited  all  its  sanitariums, 
including  the  splendid  institution  of  Doctors  Holland  and  Laws,  I 
visited  the  County  institution  about  four  miles  distant  from  the  city, 
over  West  Mountain.  Judge  of  my  surprise,  after  finding  the  color 
Hne  in  the  city  so  distinctly  drawn  as  to  require  two  separate  medical 
societies,  at  finding  the  County  Poor  House  containing  inmates,  both 
white  and  colored,  without  separate  buildings.  In  one  little  building, 
called  the  "jail,"  or  *'crazy  house,"  I  found  two  helpless  melancholic 
female  patients  in  the  midst  of  the  most  wretched  filth  and  fetor,  in 
cells  adjacent  to  three  men  afflicted  with  acute  mania,  one  of  whom 
was  colored.  One  of  these  poor  women  had  stripped  herself  of  cloth- 
ing, torn  her  bedding  to  bits,  and  during  the  recent  cold  nights  had 
her  feet  frozen,  so  that  great  sloughs  of  skin  and  fascia  were  now 
adding  to  her  discomforts.     The  crazy  negro  wanted  to  kill  somebody 


A  SURGICAL  PILGRIMAGE  TO  ARKANSAS.  201 

all  the  while.  One  of  the  men  had  epileptic  seizures  two  or  three  times 
a  day.  The  other  woman  shrieked  and  moaned  almost  incessantly, 
begging  to  be  taken  to  her  home.  A'  physician  comes  out  from  Hot 
Springs  at  intervals  to  visit  these  unfortunate  people,  instruct  the  man- 
I  ager  in  the  art  of  cleaning  the  cells,  and  making  the  occupants  comfort- 

i  able.     Other  of  the  inmates,  irrespective  of  color,  were  wandering 

^  about  the  little  frame  building  in  all  stages  of  mental  debility,  from 

low  grade  idiocy  to  the  lighter  forms  of  senile  and  moral  imbecility. 
I  had  a  talk  with  Doctor  Joseph  W.  Shaw,  at  his  office  in  Buckville, 
about  twenty-five  miles  from  Hot  Springs,  about  the  people  I  saw  in 
the  County  Poor  House,  and  he  said  they  ought  to  be  sent  to  the 
asylum  at  Little  Rock.  He  had  served  several  terms  as  a  member  of 
the  legislature  from  Montgomery  county,  and  his  son.  Doctor  Argus 
D.  Shaw,  of  Hot  Springs,  was  county  physician  at  the  Poor  House. 
Doctor  Shaw  is  a  fair  type  of  the  better  qualified  rural  practitioners  of 
Arkansas.  He  has  been  in  practice  since  the  close  of  the  Civil  War 
and  is  thoroughly  familiar  with  the  law  governing  the  care  and  med- 
ical treatment  of  pauper  and  insane  persons.  He  told  me  that  it  was 
the  custom  to  let  the  paupers  out  to  the  highest  bidder,  that  is,  a  man 
who  would  agree  to  keep  the  pauper  in  his  own  home  for  the  lowest 
figure  per  annum  would  get  the  patients ;  and  with  the  insane,  unless 
the  malady  was  pronounced,  the  same  rule  obtained.  But  when  the 
i  case  was  at  all  severe,  the  person  was  tfiken  before  the  county  judge, 

and  examined,  the  testimony  of  the  physician  in  attendance  being  taken 
and  the  patient  sent  to  the  asylum  at  Little  Rock.  I  could  not  learn 
of  any  very  careful  discriminating  examinations  to  determine  the  likeli- 
hood of  this  or  that  operation  or  treatment  being  useful  to  the  patient. 
The  county  judge  does  the  examining  and  the  physician  merely  deter- 
mines the  question  of  insanity,  basing  his  conclusions  on  the  disposition 
of  the  patient,  without  regard  for  the  pathology,  surgery  or  therapeutics 
in  the  case.  Doctor  Shaw  has  another  son  practicing  with  him,  and 
together  they  do  most  of  the  practice  within  a  radius  of  twelve  or 
fifteen  miles,  riding  the  rough  mountain  trails,  and  fording  the  moun- 
tain torrents  on  horseback.  They  have  some  malarial  fever  and  Doctor 
Shaw,  elder,  is  not  a  believer  in  all  phases  of  the  mosquito  theory. 
He  doubts  whether  the  mosquito  is  the  only  vehicle  for  the  conveyance 
of  the  Plasmodium  malariae.  There  are  occasional  cases  of  appendicitis 
occurring  in  the  mountain  regions  remote  from  the  city  hospitals  and 
surgical  sanitariums  of  Hot  Springs  and  other  cities,  wherein  the  rural 
practitioner  does  his  own  operating,  and  in  more  than  many  instances 
I  found  physicians  splendidly  equipped  with  a  knowledge  of  the  serious 
'  phases  of  abdominal  surgery.     The  city  physicians  of  Arkansas  are 

reluctant  to  go  into  the  country,  for  the  reason  that  the  people  in  the 
fastnesses  of  the  Ozarks,  though  happy,  are  often  poos,  consequently 
I  the  doctor  on  this  or  that  creek,  or  in  this  or  that  hollow,  as  the  country 

is  spoken  of,  must  do  his  serious  surgery  himself.     At  the  little  town 
of  Harrison  in  the  midst  of  a  most  rugged  country  teaming  with 


202  ORIGINAL  ARTICLES. 

I^ople  living  in  the  easy  way  of  the  Arkansan,  there  is  a  doctor  whose 
fame  keeps  him  busy  and  brings  him  all  sorts  of  surgical  cases  within 
a  radius  of  from  fifty  to  sixty  miles.  His  results  in  hernia,  appendi- 
citis, and  ovariotomy  are  just  as  good  as  those  obtained  by  any  man. 
The  pure  air,  the  fine  water  of  the  mountain  districts,  as  well  as  the 
skill  of  the  operator  are  strong  factors  in  the  recovery  of  patients. 

The  medical  visitor  at  Hot  Springs  is  not  surprised  at  the  character 
of  ills  observed  on  the  much  frequented  streets.  One  of  the  grandest 
clinics  in  the  world  may  be  observed  passing  in  an  almost  endless  pro- 
cession through  the  principal  streets  and  about  the  springs.  Just  why 
the  hot  water  emanating  from  the  earth  at  this  place  should  possess 
such  great  value  in  the  cure  of  many  chronic  ills  is  difficult  to  say,  but 
certainly  it  has  the  power  of  attenuating  and  eliminating  almost  any 
poison  contained  in  the  system  of  those  who  drink  enough  of  it.  It 
increases  voluminously  the  excretory  functions  of  the  skin,  kidneys, 
and  bowels.  The  Government  controls  the  sources  of  the  water,  there 
being  a  reservation  maintained  by  the  United  States.  Entrance  to  this 
reserve  is  indicated  by  two  huge  gate-posts,  surmounted  by  bronze 
eagles,  and  illuminated  with  the  name  of  "Hoke  Smith,'*  who  happened 
to  be  Secretary  of  the  Interior  when  certain  improvements  on  the  Gov- 
ernment Reserve  were  made.  I  cannot  but  consider  the  disfigurement 
of  these  two  splendid  gate-posts  with  the  name  of  Hoke  Smith  cut  upon 
them  a  matter  of  very  bad  taste,  but  since  this  officer  was  one  who 
cleaned  out  the  **old  mud  hole" — the  ''^old  ral  hole,"  as  it  was  called  by 
countless  thousands,  who  bathed  in  it  and  were  cured  of  their  specific 
ailments — and  substituted  for  it  the  present  free  bath-house,  where  any- 
one who  registers  his  name,  may  receive  a  bath  in  a  clean  porcelain 
tub  and  cement  pool,  free  of  charge,  I  do  not  see  why  the  medical  visitor 
at  Hot  Springs  may  not  pass  judgment  on  matter  of  taste  and  public 
policy.  It  is  not  considered  in  good  form  for  officers  of  the  United 
States  government  to  have  their  names  cut  in  the  solid  stone  to  com- 
memorate any  of  their  acts  performed  as  the  servants  of  the  people. 
The  profession  in  Hot  Springs  is  in  a  state  of  turmoil,  into  which  they 
have  dragged  the  courts,  over  the  matter  of  drumming  for  patients. 
A  X'isitors'  Protective  League  exists  among  the  physicians,  and  its 
function  is  to  ascertain  and  endeavor  to  stop  the  practice.  The  United 
States  Government  has  jurisdiction  over  the  water  coming  out  of  the 
Government  mountain  on  the  reservation  and  will  allow  only  those 
whom  it  examines  and  registers  as  competent,  qualified  physicians  to 
prescribe  the  water  for  their  patients.  There  are  a  great  many  physi- 
cians in  Hot  Springs  who  are  not  permitted  to  use  the  water  of  these 
springs  in  their  practice. 

Surgery  in  Hot  Springs  is  not  practiced  very  extensively,  as  com- 
paratively few  of  the  horde  of  invalids  coming  here  present  operable 
cases.  There  are  a  number  of  sanitariums  with  neatly  equipped  oper- 
ating rooms,  where  all  sorts  of  operations  may  be  performed.  There 
are  numbers  of  men  skilled  in  the  surgical  arts,  who  are  ready  at  any 


A  SURGICAL  PILGRIMAGE  TO  ARKANSAS.  203 

hour  of  the  day  or  night  to  perform  any  operation  needful  for  the  relief 
of  human  suffering,  and  there  are  plenty  of  trained  nurses,  too,  who 
like  surgical  cases,  but  relatively  few  operations  are  perfonned.  Hot 
Springs  is  not  a  surgical  center,  it  is  a  place  where  drugs  are  tested 
to  their  full  value  and  where  the  healing  powers  of  the  hot  waters  of 
the  earth  exert  their  greatest  efficiency.  A  curious  custom  prevails 
among  the  physicians  in  regard  to  charges.  The  consultation  fee,  or 
first  visit  of  a  patient  to  a  doctor,  is  five  dollars.  He  is  then  informed 
that  the  subsequent  charges  will  be  twenty-five  dollars  per  month, 
invariably  in  advance,  and  no  matter  what  the  disease,  the  patient 
may  come  to  the  doctor's  office  as  often  as  he  thinks  the  condition 
demands  attention.  I  was  told  that  this  rule  in  regard  to  charges  and 
custom  in  regard  to  visits  was  established  very  early  in  the  history  of 
the  springs,  that  it  works  admirably,  and  that  all  the  patients  sitting 
in  the  doctors'  waiting-rooms  represent  pay  patients,  on  the  twenty- 
five-dollars-a-month  plan.  The  doctors  are  located,  mostly,  on  one 
street,  facing  the  Government  Reservation.  Generally  their  offices  are 
over  the  stores,  and  the  patient  must  climb  a  long  flight  of  stairs.  The 
doctor,  in  prescribing  baths,  writes  his  instructions,  which  are  carried 
out  to  the  letter  in  the  bath-houses  on  the  reservation  using  the  hot 
waters.  I  saw  some  very  interesting  cases  of  necrosis  of  the  bones  of 
the  face,  nasal  bones,  grouped  about  the  hot  springs  inhaling  warm 
vapor  which  rises  from  the  waters  in  the  early  morning.  Many  of 
these  poor  people  were  in  need  of  surgery,  to  cut  away  the  diseased 
bone. 

The  country  around  about  Hot  Springs  is  mountainous,  the  town 
being  situated  in  the  foot-hills  of  the  Ozarks.  The  drainage  of  the 
country  is  through  the  Ouchita  river,  a  beautiful  stream  heading  up 
near  Indian  Territory  and  Arkansas.  The  hills  are  covered  with 
splendid  forests  of  pine,  oak,  ash,  gum,  and  hickory.  In  many  of  the 
hills  gold  has  been  found.  In  almost  any  direction  you  may  travel  on 
horseback  you  will  find  extinct  mining  camps,  where  dilapidated  build- 
ings and  rusted-out  machinery  are  to  be  seen.  The  region  for  twenty- 
five  miles  about  Hot  Springs  is  quite  thickly  populated,  notwithstanding 
the  forests,  and  nearly  every  section  of  land  has  one  or  two  families 
living  upon,  it  in  neat  little  log  cabins  with  plenty  of  children  whom  I 
found  invariably  healthy  and  happy,  subsisting  largely  on  a  diet  of 
corn  meal  which  is  grown  in  a  patch  of  rarely  more  than  four  or  five 
acres  (usually  the  only  cultivated  ground  about  the  homestead),  and 
the  delicious  meat  of  the  long-nosed,  half-wild,  razor-back  pig,  which 
thrives  the  year  around  on  roots  and  nuts.  Once  iyi  awhile  a  church 
or  a  school-house  is  found,  and  on  the  streams  occasionally  a  mill  with 
the  old  French  burrs  for  grinding  corn,  which  preceded  the  introduction 
of  the  modern  roller  process  of  milling  grain.  The  simple  diet  of  the 
native  Arkansans  who  settled  this  country  in  the  thirties  largely,  main- 
tains a  sturdy  class  of  citizens.  I  would  not  have  you  think  that  hog 
and  hominy  is  the  sole  diet  of  these  people.     The  mills  just  mentioned 


204  ORIGINAL  ARTICLES. 

make  splendid  meal  of  the  pure  hard  corn,  which  thrives  everywhere 
in  the  country  around  Hot  Springs.  This  meal  contains  all  the  nutri- 
tive elements  of  the  grain,  and  is  quite  different  from  the  product  of  our 
northern  mills.  The  people  have  cattle  and  use  milk  and  butter  to  a 
moderate  extent.  They  are  not,  however,  well  posted  in  the  science  of 
dairying,  and  I  fear  the  rugged  little  cattle  are  not  profitable  producers 
of  fat.  They  are  so  numerous  in  the  country  I  traveled  over  that  they 
have  devoured  all  the  canebrake  which  used  to  fill  the  valleys  and  low 
places  along  the  mountain  streams.  Their  hides  are  a  source  of  income 
to  the  mountain  farmer,  or  cracker,  as  he  is  sometimes  called.  Inquiry 
revealed  an  occasional  case  of  anthrax  and  progressive  purulent  infec- 
tion of  the  hands  of  persons  who  had  been  handling  hides  of  cattle 
found  dead  in  the  woods.  I  could  not  learn  that  deaths  were  due  to 
tuberculosis  among  the  cattle,  but  believe  that  they  were  the  result 
of  insufficient  food  during  the  winter  period,  a  little  shorter  though 
much  less  severe,  than  that  of  Michigan.  The  people  are  beginning 
to  learn  the  value  of  poultry  as  a  food,  and  as  a  means  of  increasing 
the  family  revenue.  I  found  fine  chickens  about  every  homestead,  and 
fresh  eggs  and  fresh  fowl  supplement  the  pork  and  corn  meal  diet  I 
have  been  writing  about.  In  the  little  field  about  the  house,  are  com-  * 
monly  grown  a  few  potatoes  of  the  Irish  variety,  and  a  larger  quantity 
of  sweet  potatoes,  which  are  secured  for  use  through  the  winter  season. 
Cabbage,  turnips,  cauliflower,  tomatoes  and  all  sorts  of  wild  fruits  and 
berries  are  valuable  adjuvants  to  the  foods  I  have  just  mentioned. 
The  total  cost  of  living  on  a  good  wholesome  diet  in  the  country  round 
about  Hot  Springs  is  surely  not  very  high.  Corn  is  worth  fifty-five 
cents  a  bushel  shelled,  a  bushel  loses  one-eighth  in  the  process  of  grind- 
ing, and  will  feed,  when  made  into  meal,  a  family  of  five  persons  three 
weeks.  That  is  only  two  and  one-half  cents  per  day.  The  pork,  dressed, 
is  worth  six  dollars  a  hundred,  and  a  family  of  five  persons  will  eat 
three  hundred  sixty-five  pounds  a  year.  That  is  about  six  cents  a  day, 
making  the  total  cost  of  living  for  a  family  of  five  persons  about  eight 
cents  a  day.  That  this  diet,  inexpensive  as  it  is,  is  sufficient  for  good 
sound  health  and  mental  vigor  is  amply  attested  by  the  freedom  of  the 
people  from  tuberculous  infections,  chronic  anemia,  or  neuritis. 

Not  a  small  part  of  the  curative  value  of  a  sojourn  at  Hot  Springs 
is  due  to  frequent  excursions,  either  on  foot  or  on  horseback,  into  the 
mountainous  country  round  about  the  town.  The  better  qualified  phy- 
sicians nowadays  advise  these  excursions  as  a  part  of  routine  treatment 
accompanying  the  baths,  and  they  are  of  fully  as  much  value  as  the 
massage  and  inunctions  liberally  practiced.  I  could  not  learn  that 
anyone  was  doing  anything  in  a  surgical  way  for  the  cure  of  nerve 
syphilis.  Tlie  well-known  fact  that  a  surgical  operation  upon  the  cra- 
nium— opening  the  bony  vault  of  the  skull  with  the  trephan — often 
determines  the  action  of  the  iodide  of  potash  in  these  cases  of  cerebral 
disease  commonly  attributed  to  venereal  infections,  seems  to  have  passed 
unnoticed. 


A  SURGICAL  PILGRIMAGE  TO  ARKANSAS.  206 

Eureka  Springs,  in  the  northwest  corner  of  Arkansas,  has  a  wide 
reputation  on  account  of  the  purity  of  its  waters.  They  are  quite  free 
from  solids,  and  are  cold,  carrying  more  oxygen  than  the  waters  of 
Hot  Springs.  The  purity  of  its  air,  and  the  very  rugged,  broken  char- 
acter of  the  country  in  which  they  are  located,  commands  attention. 
There  are  more  than  forty  springs  inside  the  town,  and  one  can  get  his 
fill  of  the  solvent  diluent  at  almost  every  corner.  In  the  treatment  of 
rheumatism  and  nephritis,  these  waters  are  quite  unsurpassed.  The 
man  with  the  torpid,  sluggish  liver,  renal  insufficiency,  and  a  feeble 
heart,  will,  if  he  drinks  these  waters  and  climbs  these  hills  under  the 
direction  of  a  skilled  physician,  commonly  find  the  obstruction  to  his 
circulation  soon  disappear,  his  respiration  grows  less  frequent,  his 
sleep  become  less  fitful  and  restless,  and  his  general  condition  vastly 
improved ;  but  even  here  I  found,  in  conversation  with  physicians,  that 
a  high  degree  of  skill  is  necessary  to  achieve  results  in  the  treatment  of 
rheumatism,  nephritis,  eczema,  or  the  distressing  pruritus,  often  found  as 
symptoms  of  impaired  nutrition  of  the  central  nervous  system.  Nor  is 
Eureka  Springs  a  surgical  town ;  there  is  not  a  hospital  or  sanitarium 
in  the  town.  All  the  surgery  is  the  homemade  sort,  and  is  per- 
formed wherever  the  need  of  it  is  manifest.  People  with  tumors  do 
not  come  here,  although  I  believe  not  a  few  cases  might  be  found  in 
which  the  solvent  action  of  the  water  in  cases  of  chronic  empyema  of 
the  gall-bladder,  and  the  agglutination  of  the  ducts  might  be  supple- 
mented by  a  surgical  operation  for  drainage  of  the  gall-bladder.  Bath- 
houses are  plentiful,  fine  hotels  are  numerous,  good  food  is  abundant, 
and  pure  air  is  universal  at  Eureka  Springs.  In  a  talk  with  Doctor 
Russell  G.  Floyd,  who  has  a  wide  reputation  in  the  treatment  of 
nephritis,  I  was  pleased  to  learn  that  he  advised  stripping  the  kidney 
in  many  of  the  cases  of  water-log  nephritis,  that  he  gave  the  patient 
plenty  of  the  pure  waters  of  the  springs  to  drink,  that  he  prescribed 
digitalis,  and  that  he  subjected  them  to  vapor  baths,  massage,  and  cold 
douches  with  the  most  gratifying  results.  Doctor  Floyd  invariably 
treats  the  eczemas  and  pruritics  with  copious  dilutions  of  the  fluids  of 
the  body,  by  having  the  patient  drink  daily  one  or  two  gallons  of  the 
pure  spring  water,  and  bathe  in  warm  spring  water,  whitened  with 
bags  containing  four  or  five  pounds  of  bran  to  each  twenty  gallons  of 
water.  Exercise  on  the  hills,  climbing  the  mountain  paths,  or  follow- 
ing the  bridk  trails  on  horseback  are  valuable  accessories  of  his  treat- 
ment. The  country  here  is  free  from  mosquitoes,  and  no  stagnant 
water  is  found  anywhere.  The  whole  region  around  about  is  underlaid 
with  caverns,  and  into  these  the  waters  filter  through  the  flinty  soil, 
to  appear  finally  in  the  beautiful  strong  flowing  White  river  which 
rises  in  and  drains  this  region  of  the  Ozarks. 

I  learned  of  a  fever  not  altogether  rare,  which  the  doctors  told  me 
is  neither  typhoid  nor  malaria,  but  may  be  appendicial.  It  seizes  the 
patient  in  the  form  of  a  high  temperature,  lasts  from  three  to  four 
weeks,  and  commonly  ends  in  recovery  if  treated  with  hot  sponge 


206  ORIGINAL  ARTICLES. 

bathing.  It  lacks  the  stepladder  rise  of  temperature  in  typhoid,  as  well 
as  the  intermission  and  the  remission  of  the  malarial  fevers.  Xor  is  it 
in  the  least  influenced  by  quinine.  It  occurs  at  almost  any  season  of 
the  year  and  is  found  in  any  part  of  the  Ozark  mountains.  The  local 
doctors  call  it  mountain  fever,  slow  fever.  It  is  never  epidemic,  nor 
is  it  moscjuito-born,  for  it  prevails  in  localities  where  mosquitos  are 
never  seen.  There  is  tenderness  in  the  reg^ion  of  the  appendix  in  most 
of  the  cases,  quite  suggestive  of  appendicitis.  May  it  not  be  a  type 
of  ulceration  of  the  appendix  mucosa,  allied  to  the  ulceration  of  Pyer*s 
patches,  a  characteristic  of  typhoid?  Near  the  I>asin  Park  Hotel  is  a 
large  spring  and  a  little  park,  where,  during  the  Ix-ttcr  ])art  of  the  two 
himdred  odd  bright  days  of  the  year,  may  be  seen  numbers  of  people, 
who  come  here  to  drink  the  water,  and  increase  their  stock  of  health. 
The  pallid  face,  the  puffy  eyelids,  and  the  hurried  respiration  of  the 
nephritic  patient  is  frequently  seen  among  them,  and  in  almost  every 
instance  these  people  are  improved,  not  a  few  being  absolutely  cured 
by  the  waters  of  the  springs  and  surgical  stripping  of  the  kidney. 

Fort  Smith.  Arkansas,  is  a  city  of  twenty  odd  thousand  people  on 
the  border  of  Indian  Territory.  It  is  in  Sebastian  county  on  the 
Arkansas  river  at  the  head  of  steamboat  navigation.  The  Sebastian 
County  Medical  Society  has  a  membership  of  forty-two,  but  there  are 
about  one  hundred  seventy-five  doctors  in  the  city,  and  they  are  all 
either  irregulars,  eclectics,  or  homeopaths.  The  mass  of  practice  is 
in  the  hands  of  the  irregulars.  The  profession  lives  in  reasonable 
harmony.  There  are  several  very  good  surgeons,  who  operate  at  the 
City  Hospital  and  at  the  Saint  Vincent,  a  Catholic  hospital.  There  is, 
however,  no  great  amount  of  surgery  done.  Some  of  the  operators 
having  met  with  disaster  in  their  abdominal  work  have  caused  the 
people  generally  to  be  averse  to  surgical  procedures.  They  prefer  to 
trust  to  powdered  roots,  fluid  extracts,  and  divers  teas  for  the  relief 
of  their  ills.  Some  of  the  doctors,  however,  have  large  practice,  visit 
a  great  many  patients,  and  put  up  or  dispense  bushels  of  medicine. 
Malarial  fevers  are  not  uncommon.  Quinine  and  other  alkaloids  of 
Peruvian  bark  are  in  constant  use.  Calomel  and  epsom  salt  seem  to 
be  effective  in  most  of  the  abdominal  cases.  The  positive  obstructions 
are  either  operated  upon,  with  more  or  less  reluctance,  or  go  surely  to 
the  bad.  I  could  not  learn  that  there  was  much  surgical  enthusiasm 
in  Fort  Smith.  It  is  a  fine  growing  city,  full  of  splendid  homes,  in 
the  midst  of  a  fertile  country,  maintains  two  ambulances  owned  by 
undertakers,  who  are  a  thrifty  class.  There  is  an.  opportunity  in  Fort 
Smith  for  an  apostle  of  surgery,  but  he  must  cure  the  people  whom  he 
operates  upon. 

My  medical  jaunt  to  Arkansas  would  not  be  complete  without  some 
account  of  Little  Rock,  the  capital  of  the  state,  wdiere  are  located  the 
niedical  department  of  the  Arkansas  Industrial  University,  Saint  Vin- 
cent's Hospital,  and  the  Logan  H.  Root  Hospital.  Mr.  Root  endowed 
the  hospital  with  $too.ooo,  but  only  $10,000  of  that  sum  was  found 


A  SURGICAL  PILGRIMAGE  TO  ARKANSAS.  207 

available  by  his  executors  for  the  uses  of  the  institution.  The  clinics 
of  the  medical  college  are  in  part  held  there,  and  as  good  courses  in 
clinical  medicine  and  surgery  are  given  in  Little  Rock  as  in  any  city 
of  its  size  in  the  United  States.  The  Medical  College  was  founded 
about  twenty  years  ago  and  it  numbers  among  its  alumni  many  of  the 
ablest  physicians  of  the  state.  Little  Rock  has  about  fifty  thousand 
people  and  is  growing.  It  has  Saint  Vincent's  Hospital,  a  church 
institution;  a  Railroad  Hospital  under  the  care  of  Doctor  Joseph 
P.  Runyon,  who  is  generally  recognized  as  one  of  the  leading  surgeons 
of  the  city ;  and  a  City  Hospital,  in  charge  of  Doctor  Watkins,  the  city 
physician.  At  the  County  Hospital  and  Poor  House,  a  short  distance 
from  the  city,  senior  medical  students  act  as  internes,  and  get  a  part  of 
their  course  in  clinical  obstetrics.  Little  Rock  has  a  School  for  the 
Blind — both  white  and  colored,  a  School  for  the  Deaf — both  white  and 
colored,  the  State  Penitentiary,  and  the  Asylum  for  the  Insane,  which 
contains  more  than  one  thousand  patients.  All  of  these  institutions 
furnish  more  or  less  medical  and  surgical  work,  which  is  available  for 
the  instruction  of  industrious  and  enterprising  medical  men.  In  the 
Asylum  for  the  Insane  the  custodial  features  of  the  work  is  paramount, 
but  not  a  little  attention,  probably  fully  as  much  as  in  asylums  generally, 
is  given  to  the  internal  medication  of  the  patients.  Gastrointestinal 
work  is  done  tentatively,  but  every  patient  is  given  a  careful  physical 
examination,  which  supplements  the  perfunctory  examination  carried 
out  under  the  direction  of  the  county  judge.  There  is,  however,  no 
reason  to  contrast  the  medical  and  surgical  care  of  the  insane  of  Arkan- 
sas, outside  of  the  Poor  House  in  Garland  county,  with  the  care  that 
is  given  those  people  in  other  states.  At  Fort  Smith  they  have  a  fine 
Poor  House  under  the  care  of  able  physicians,  and  the  most  conscien- 
tious and  discriminating  treatment  is  given  to  the  patients.  The  same 
may  be  said  of  that  institution  at  Little  Rock  and  of  the  asylums  gen- 
erally. The  blot  on  the  escutcheon  of  Arkansas  in  Garland  county, 
near  Little  Rock,  a  prominent  physician  in  Little  Rock  told  me,  is  the 
fact  that  Hot  Springs  is  the  mecca  for  countless  thousands  of  people, 
mostly  poor,  who  suflfer  from  constitutional  diseases  and  pour  into  Hot 
Springs  in  great  numbers.  If  the  municipality  built  a  city  hospital 
they  would  swamp  it.  If  they  kept  a  decent  Poor  House  they  would 
swamp  it.  ]\Iost  of  the  inmates  of  the  County  Poor  House  were  from 
other  counties  and  states,  who  had  come  to  Hot  Springs  with  the  hope 
that  the  hot  waters  would  heal  them,  and  had  no  means  to  get  away. 
He  further  said  that  it  was  the  policy  of  the  municipality  of  Hot 
Springs  to  discourage  the  coming  of  poor  people  to  that  place,  by  with- 
holding all  the  usual  eleemosynary  institutions  from  their  use.  Even 
the  jail,  I  found  overcrowded  and  a  relic  of  antiquity.  It  was  built 
in  the  early  days  of  the  county  and  ought  to  discourage  every  evil- 
minded  person  w'ho  looks  at  it,  much  less  stays  in  it. 

The  expectation  of  finding  any  considerable  amount  of  up-to-date 
surgery  and  surgical  institutions  in  Arkansas  were  not  fruitless;  and 


208  ORIGINAL  ARTICLES. 

there  is  good  reason  to  believe  that  the  small  band  of  vigorous,  aggress- 
ive, well-equipped  practitioners  of  the  chirurgic  art  will  meet  with 
better  reward  in  the  near  future.  The  wealth  of  Arkansas  forests,  her 
mines  of  coal  and  metal,  her  cattle,  sheep  and  hogs,  her  grain  and  cotton 
cannot  help  but  bring  a  population  which  will  want  more  and  better 
schools,  ask  more  and  better  care  of  their  minds  and  bodies,  and  con- 
sequently give  employment  liberal  and  ample  to  those  who  stand  today 
.  for  the  advancement  of  medicine  along  the  most  progressive  lines. 


THE  VALUE  OF  TIME  AND  NATURAL  UTERINE  EFFORTS 
IN  PARTURITION.* 

By  ALVAH  N.  COLLINS,  M.  D,  Detroit. 

If  the  signs  of  the  times  indicate  anything  to  the  more  mature 
medical  student,  they  indicate  a  closer  study  of  the  natural  processes 
in  the  care  and  cure  of  those  seeking  our  advice  and  assistance.  This 
is  true  as  well  of  surgery  as  it  is  in  so-called  general  medicine  and 
obstetrics.  In  general  medicine  we  cannot  fail  to  note  a  falling  off  in 
complex  drugging  and  active  interference.  Given  a  complex  prescrip- 
tion containing  a  4ialf  dozen  different  ingredients,  the  ultimate  action 
of  which,  given  separately,  we  know  little  enough,  when  combined,  we 
know  less.  We  had  a  specific  that  was  good  for  this  symptom  and 
that  symptom,  while  at  the  same  time  it  might  be  hammering  the  life 
out  of  some  other  vital  part  of  our  machinery,  unnoticed,  in  our  mad 
pursuit  of  the  particular  symptom.  How  the  multitudinous  remedies 
have  dwindled  in  this  renaissance  of  more  accurate  observation.  Just 
now  in  all  branches  of  medicine  the  pendulum  of  all  active  interference 
without  a  very  plain  indication  is  swinging  back  toward  a  reasonable 
letting  alone  of  all  the  natural  processes  unless  we  have  a  plain  indi- 
cation for  interfering,  either  mechanically  or  medicinally,  with  an 
organization  in  which  countless  generations  have  developed  recuper- 
ative and  curative  properties  and  which,  in  many  cases,  now  interfered 
with  were  much  better  left  alone.  The  man  who  always  has  his 
monkey-wrench  in  his  automobile  will  do  considarable  walking.  The 
doctor  who  cannot  keep  his  fingers  out  of  the  delicate  processes  of  the 
animal  machinery  will  often  do  irreparable  damage  to  the  nicely 
adjusted  and  wonderfully  complex  machinery  of  the  living  organfsm. 
Nevertheless,  there  are  times  when  the  monkey-wrench  will  help  the 
machine  and  there  are  unquestionably  times  when  the  careful  physician 
will  assist  in  benefiting  the  laboring  organism.  I  simply  plead  for  more 
care  and  judgment  when  to,  and  when  not  to,  interfere.  If  a  labor  is 
going  along  reasonably  well,  if  there  are  no  apparent  reasons  why  a 
natural  labor  may  not  be  consummated,  in  the  name  of  all  that  is 
sacred  let  it  alone. 

•Read  at  the  Ann  Arbor  meeting  of  the  First  Councilor  District  Mrdical  Soci- 
ety, December  22,  1905. 


NATURAL  EFFORTS  IN  PARTURITION.  209 

The  subject  of  obstetrics  is  a  broad  one,  and  I  will  confine  myself 
to  one  phase — the  value  of  time  and  natural  uterine  efforts  in  parturi- 
tion— drawing  my  conclusion  very  largely  from  mistakes  that  I  have 
made  myself,  and  from  mistakes  that  I  have  seen,  and  known  of  others 
making.  In  an  experience  extending  over  a  period  of  twenty  years 
it  was  my  misfortune  to  have  a  very  large  obstetric  practice.  I  cannot 
compete  with  some  figures  I  have  heard  as  to  number  of  cases  so  will 
give  no  figures,  but  conclusions  drawn  not  so  much  from  books  as 
from  the  bedside.  We  need  to  have  a  fairly  definite  knowledge  of 
what  is  the  average  time  necessary  for  normal  labor.  We  must  take  into 
consideration  that  this  is  so  modified  by  individual  peculiarifies  that 
one  patient  may  need  hours  for  certain  changes  that  are  necessary  for 
safe  delivery  to  take  place  while  another  will  only  need  minutes.  Each 
patient  has  a  normal  period  of  time  distinctly  her  own.  Yet  from  the 
study  of  a  large  number  of  cases  we  estimate  a  fairly  definite  period 
during  which  the  process  is  completed.  This  period,  as  you  have  all 
observed,  often  varies  greatly  in  the  same  patient,  differing  presenta- 
tions, differing  size  of  child,  differing  physical  conditions,  et  cetera, 
all  modifying  the  time  needed  for  the  most  conservative  and  safe  com- 
pletion of  this  truly  awful  phenomenon,  parturition. 

Hirst  states  that  the  average  duration  of  all  labors  is  from  twelve 
to  fifteen  hours:  in  primaparae  from  twelve  to  twenty- four  hours;  in 
multipara  from  six  to  twelve  hours. 

In  Spiegelberg's  five  hundred  and  six  cases,  commonly  quoted,  the 
three  stages  for  primiparae  are,  stage  of  dilatation,  fifteen  hours ;  expul- 
sion, two  hours;  third  stage,  one-half  hour.  Multiparae — dilatation, 
eight  hours ;  expulsion,  one  hour ;  and  placental,  one-half  hour.  A  proper 
conception  of  -the  long  time  necessary  to  bring  about  a  condition  of  the 
parts  for  a  safe  delivery,  a  delivery  as  free  from  injury  to  the  struc- 
ture of  the  parturient  canal  and  with  as  little  offense  to  those  organs 
as  is  possible,  is  the  sine  qua  non  of  obstetrical  practice. 

My  observation  and  experience  at  the  bedside  have  shown  me  con- 
clusively that  more  damage  is  needlessly  done  from  a  failure  to  remem- 
ber that  the  normal  period  of  the  stage  of  dilatation  in  primiparae  is 
fifteen  hours  and  may  be  thirty-six  hours  or  more  and  still  be  normal 
for  that  case,  than  from  any  other  one  cause.  I  am  satisfied  that 
many  a  woman  in  her  first  labor  is  unnecessarily  injured  and  made  a 
semiinvalid,  forever  after  to  be  a  supplicant  at  the  shrine  of  the  gyne- 
cologist, from  this  failure  on  the  part  of  the  attendant  to  properly 
realize  the  necessity  and  value  of  time  for  the  physiological  changes  to 
be  brought  about  for  safe  delivery.  I  am  not  discussing  abnormal 
conditions.  Abnormal  conditions  may  imperatively  demand  violent 
treatment  of  these  organs  as  a  lesser  of  two  evils.  Whenever  we  for- 
get the  value  of  time  in  parturition,  and  with  our  anesthesia  and  our 
forceps  force  these  delicate  structures  to  dilate  and  stretch  to  their 
utmost  and  beyond  before  they  have  been  prepared  for  the  ordeal  by 


210  ORIGINAL  ARTICLES 

hours  of  natural  effort  we  are  meddling  with  a  process  greatly  better 
let  alone. 

The  process  of  dilatation  of  the  cervix,  the  obliteration  of  the  cer- 
vical canal,  the  relaxation  of  the  lower  uterine  segment  or  the  so- 
called  ring  of  Bandl  is  a  slow  process.  If  given  time  the  uterine  con- 
tractions, pulling  by  the  longitudinal  fibers  from  above  against  a  con- 
ical wedge  within  the  uterus,  gradually  dilate  the  opening,  making 
the  heretofore  contracted  canal  a  cylindrical  part  of  the  uterine  body, 
permitting  the  escape  of  its  contents  without  great  injury  to  its  own 
structure  or  unnecessary  pull  upon  the  ligaments  supporting  the 
uterus.  This  dilatation  can  by  no  mechanical  means  known,  be  so 
safely  accomplished  as  by  the  physiological  process  attending  the 
phenomena.  A  certain  degree  of  edematous  infiltration  of  the  lower 
segment  results  from  the  paroxysmal  contraction  and  the  relaxation, 
which  requires  time.  This  infiltration  permits  relaxation  without 
laceration. 

In  the  second  stage  of  labor,  in  preparing  the  pelvic  floor  and 
vaginal  outlet  and  perineum  for  the  great  distention  that  is  to  come, 
this  infiltration  is  undoubtedly  of  the  greatest  value  in  permitting  a 
relaxation  without  rupture.  This  process  of  infiltration  requires  time. 
In  the  second  stage,  especially  in  primiparae,  without  very  clear  indica- 
tion of  necessity  for  hasty  delivery,  we  should  permit  all  the  protective 
processes  of  infiltration,  paroxysmal  distension  and  recession,  and 
gradual  dilatation ;  ample  time  to  prepare  for  the  stretching  that  must 
otherwise  result  in  laceration;  which  in  the  majority  of  cases  physio- 
logic law  exacts.  How  unwise  and  how  unscientific  then  does  it 
become  to  resort  to  forceps  before  we  have  the  best  possible  obliter- 
ation of  the  cervical  canal  and  lower  uterine  segment  which  terminates 
the  first  stage  of  labor. 

To  apply  the  forceps  high  up  before  the  head  has  entered  the  brim 
or  descended  into  the  excavation,  even  with  a  well  dilated  or  dilatable 
lower  segment,  is  a  dangerous  procedure,  I  quote  from  the  "Ameri- 
can Text-Book  of  Obstetrics":  "It  should  be  resorted  to  only  in 
exceptional  cases.  The  higher  the  head  the  more  dangerous  the  pro- 
cedure." How  much  more  dangerous  to  apply  high  forceps  before  we 
have  a  proper  dilatation  and  exert  the  strength  often  applied  to  the  pull 
upon  a  lower  undilated  uterine  segment.  What  are  we  pulling  upon  ? 
We  are  dragging  with  all  the  force  exerted,  upon  the  uterine  ligaments, 
the  round  ligaments,  lower  part  of  the  broad  ligaments  and  the  utero- 
sacral  bands.  If  the  bony  structure  of  the  pelvis  resists  us  we  then 
endanger  the  anterior  supports  of  the  bladder,  urethra,  and  vagina. 
If  our  eflforts  are  successful  in  dislodging  the  head  from  the  rapidly 
dilated  lower  segments,  what  then  occurs  if  we  continue  with  our 
delivery  ?  '  We  bring  the  head  down  upon  the  pelvic  floor  and  peri- 
neum to  the  second  stage  of  labor  which  requires  normally  two  hours 
and  may  normally  require  from  two  to  six  hours.     Do  we  sit  there 


NATURAL  EFFORTS  IN  PARTURITION.  ^  211 

from  two  to  six  hours  or  permit  a  proper  time  for  the  proper  relaxa- 
tion of  this  pelvic  floor?  We  should  if  we  are  to  properly  protect  our 
patient.  As  a  rule,  when  the  forceps  are  on,  the  process  is  continual 
and  the  delivery  completed  within  an  hour  at  the  outside.  The  result 
is  unnecessary  injury.  We  have  not  taken  into  consideration  the 
value  of  time  in  this  process.  This  picture  is  not  overdrawn.  A  short 
time  ago  I  was  called  to  repair  a  primiparae  where  the  whole  process 
of  the  three  stages  had  been  accomplished  with  the  forceps  in  about 
four  hours.  The  result  was  two  tired  physicians  and  a  genital  tract 
that  looked  as  though  a  stick  of  dynamite  had  been  inserted  therein 
and  exploded.  No  sugeon  can  by  any  sort  of  repair  ever  overcome  the 
damage  done.  The  only  recourse  is  to  make  the  best,  by  careful  effort, 
of  what  was  rendered  irreparable.  It  is  because  I  have  witnessed  this 
sort  of  work  so  long  that  I  wish  to  call  attention  to  the  trite  subject — 
the  value  of  time  and  natural  uterine  efforts  in  parturition.  Again,  in 
induced  premature  labor,  I  have  seen  the  process  so  unduly  hurried 
that  a  small  child  rapidly  delivered  caused  such  shock  that  the  mother 
never  recovered.  Do  not  understand  me  to  be  criticizing  necessary  haste 
when  haste  is  plainly  the  lesser  of  two  evils ;  but  I  wish  to  emphasize 
the  dangers  of  too  rapid  delivery.  I  wish  to  state  my  conviction  that 
in  many  cases  of  delivery  today  the  forceps  are  used  altogether  too 
early  and  too  often.  We  should  not  permit  a  woman  to  die  of 
exhaustion,  but  the  proportion  of  women  dying  of  exhaustion  and 
delayed  labor  are  few  compared  with  those  invalided  for  life  and  dying 
from  precipitate  artificial  delivery. 

Is  there  need  to  again  direct  attention  to  the  evil  results  of  hasty 
and  forced  delivery  in  the  normal  but  slow  parturient  wcMnan?  My 
experience  answers  this  question  in  the  aflirmative  most  emphatically. 
Once  a  pelvic  floor  is  severely  torn  I  very  much  doubt  if  any  care, 
no  matter  how  skillful  the  surgeon,  can  restore  it  to  its  original  tone 
and  function.  We  may  carefully  adjust  the  torn  muscle  and  tissue 
in  sight  or  in  reach  but  we  cannot  see  or  reach  the  upper  margin  of 
the  support.  Recognizing  this  impossibility^  of  complete  restoration 
it  becomes  imperative  that  we  use  every  means  at  command  to  prevent 
a  condition  being  brought  about  which  is  incapable  of  repair.  In  my 
judgment  the  most  efficient  protection  against  calamities,  farreaching 
in  their  immediate  as  well  as  remote  effects,  is  in  allowing  plenty  of 
time  for  the  natural  protective  processes  to  physiologically  prepare  this 
tissue  for  its  great  distention.  If  given  plenty  of  time  a  very  difficult 
delivery,  if  forced,  becomes  relatively  jeasy  and  free  from  danger.  In 
many  cases  of  prolapsus  in  later  life  the  so-called  rectocele  and  cysto- 
cele  are  due  to  too  rapid  delivery  in  the  second  stage  of  labor.  No 
matter  how  carefully  we  may  repair  a  perineum  or  how  perfect  our 
union,  a  vagina  once  torn  from  its  pelvic  attachments  is  very  difficult 
if  not  impossible  to  repair.     This  detachment  may  be  and  usually  is 


212  ORIGINAL  ARTICLES. 

subcutaneous  and  undetected  till  the  woman  has  been  on  her  feet 
several  weeks. 

There  can  be  no  reasonable  doubt  but  that  the  early  use  of  the  for- 
ceps and  the  semivoluntary  excessive  bearing  down  of  the  patient,  or 
in  other  words,  too  rapid  movement  in  the  second  stage  of  labor,  is  the 
prime  cause  of  this  tearing  away  of  the  pelvic  attachments  of  the 
vagina,  the  results  of  which  are  rectocele,  cystocele,  and  later  in  life 
uterine  prolapse.  If  this  be  true,  in  most  cases  we  do  our  most  effi- 
cient service  by  retarding  rather  than  hastening  the  second  stage  of 
labor.  With  no  contraindication  I  believe  this  procedure  should  nearly 
always  be  done  by  employing  anesthesia  and  exerting  manual  press- 
ure upon  the  distended  perineum.  This  can  usually  be  accomplished 
by  giving  the  parts  ample  time  to  relax  to  their  utmost.  You  are  all 
familiar  with  the  complete  lacerations  often  found  in  cases  of  precipi- 
tate labor  when  there  has  been  no  opportunity  to  protect  these  tissues 
by  compelling  a  slower  process.  They  but  teach  us  what  not  to  do 
with  our  forceps  and  how  to  protect  these  structures  when  opportunity 
is  given. 

In  the  delivery  of  the  oncoming  shoulder,  time  again  should  be 
given.  No  doubt  deep  pelvic  floor  injury  is  often  increased  if  not 
caused  by  a  too  rapid  shoulder  delivery.  Time  is  here  needed  for 
rotation  and  adjustment  of  the  bisacromial  diameters  to  the  antero- 
posterior diameter  of  the  outlet.  With  the  anterior  shoulder  behind 
the  pubic  bone,  the  cervicoacromial  diameter  permits  the  posterior 
shoulder  to  emerge  first  with  less  strain  upon  the  pelvic  floor.  When- 
ever possible,  with  no  contraindications  aside  from  gently  elevating 
the  head,  the  posterior  shoulder  should  be  allowed  to  pass  over 
the  perineum  with  no  effort  at  manual  extraction  whatever.  This 
method  of  shoulder  delivery  is  the  natural  one  and  simply  requires  let- 
ting alone  largely  till  the  physiologic  forces  complete  their  work.  If 
any  traction  should  be  required  in  the  delivery  of  a  large  child  the  pos- 
terior foreams  should  be  gently  flexed  out  over  the  perineum  and  a 
gentle  traction  upon  the  posterior  shoulder  made,  allowing  the  yielding 
body  to  permit  the  delivery  of  the  anterior  shoulder  under  the  pubic 
arch.  Again,  in  the  third  stage  or  placental  delivery  the  element  of 
time  is  too  often  overlooked,  and  pushing  from  above  and  lugging  at 
the  cord  below  is  resorted  to  instead  of  gently  kneading  the  uterus  and 
permitting  a  natural  and  complete  delivery.  You  are  all  familiar  with 
the  saying  that  adherent  placentae  are  found  mostly  in  the  first  few 
cases  attended.  It  is  surprising  how  seldom  they  are  found  later  in 
our  professional  careers.  It  requires  from  five  to  ten  minutes  for  the 
relaxed  and  relatively  empty  uterus  to  regain  sufficient  contractability 
to  commence  efforts  of  placental  expulsion.  Its  first  efforts  are  usu- 
ally futile.  More  time  and  more  stripping  oflF  by  the  retained  blood 
are  required.  The  only  point  we  need  to  know  is,  has  the  uterus  its 
tone?     This,  by  manual  touch  through  the  abdominal  wall,  is  readily 


NATURAL  EFFORTS  IN  PARTURITION.  213 

determined.  If  permitted,  within  fifteen  minutes  or  a  half  hour  the 
process  will  be  completed  in  a  way  more  satisfactory  and  safe  than  man 
has  devised.     Again,  the  value  of  time  versus  meddling ! 

CONCLUSION. 

It  requires  time  to  bring  about  a  proper  condition  of  the  cervix  and 
lower  segment  of  the  uterus  for  the  safe  delivery  of  the  presenting 
part.  This  is  a  variable  time,  and  when  there  are  no  urgent  contra- 
indications this  time  should  be  given — be  it  three  hours  or  three  days. 
My  experience  and  observation  force  me  to  conclude  that  this  is  very 
often  forgotten  at  the  beside,  with  lamentabte  consequences  to  our 
patients.  The  forceps  are  applied  altogether  too  frequently  and  alto- 
gether too  early  in  a  great  number  of  cases.  When  employed  they 
are  not  used  with  sufficient  deliberation,  and  results  are  brought 
about  in  minutes  which,  in  order  to  properly  protect  the  tissues,  should 
take  much  longer  time.  The  strain  upon  the  tissues  is  too  continuous 
to  properly  protect  the  child  or  the  maternal  tissues.  The  strain  should 
be  interrupted  instead  of  continuous.  The  interval  of  strain  should 
not  exceed  one-half  minute  without  a  relaxation.  More  time  than  is 
usually  given  is  imperatively  required  if  we  are  to  relax  instead  of 
tear  the  tissues.  We  should  not  forget  that  we  are  pulling  upon  deli- 
cate structures  which  must  oppose  our  strength  with  theirs,  pound  for 
pound.  We  should  not  forget  that  before  time  for  relaxation  has  been 
given  a  force  of  fifty  pounds  will  do  more  damage  and  accomplish  less 
than  a  ten-pound  pull  with  proper  relaxation.  We  need  to  fix  in  our 
mind  the  time  for  the  various  stages  of  normal  labor  and  conform  as 
nearly  as  conditions  will  permit  to  these  periods,  not  forgetting  that 
more  time  in  individual  cases  may  be  given  when  there  are  no  plain 
contraindications.  Watch  the  progress  of  natural  labor  with  more 
of  a  readiness  to  assist  natural  processes  than  with  an  idea  of  taking 
the  job  entirely  into  our  own  hands.  I  quote  the  indications  for  the 
use  of  forceps  from  the  "American  Text-Book  of  Obstetrics.'* 

(i)  Indicated  in  lingering  labor  when  the  natural  efforts  are 
unable  to  effect  delivery. 

(2)  When  speedy  delivery  is  imperative  in  the  interest  of  the 
mother;  as  in  hemorrhage,  exhaustion,  convulsion,  advanced  cardiac 
or  pulmonary  diseases,  et  cetera. 

(3)  When  speedy  delivery  is  indicated  in  the  interests  of  the  child, 
as  in  impending  death  of  the  mother  or  threatened  asphyxia  of  the 
child. 

And  again,  a  quotation  from  Doctor  John  W.  Clark  in  his  "Resume 
of  Prolapsus,''  published  in  the  June  (1905)  number  of  "Progressive 
Medicine,"  expresses  the  facts  of  this  subject : 

( I )  Never  encourage  a  patient  in  labor  to  bear  down  until  nature 
excites  this  inclination. 


214  ORIGINAL  ARTICLES. 

(2)  The  use  by  the  patient  of  tractors  to  increase  the  voluntary 
expulsion  effort  is  questionable. 

(3)  Never  apply  forceps  without  a  complete  dilatation  of  the  cer- 
vix. When  a  more  precipitate  delivery  is  necessary  it  is  best  to  incise 
the  cervix. 

Never  use  forceps  without  a  positive  indication.  Secure  the  gradual 
passage  of  the  head  through  the  vagina  and  over  the  perineum. 
The  prevalent  use  of  artificial  force,  the  habitual  use  of  the  forceps 
without  any  prime  indication  for  their  use,  the  rapidity  with  which 
labor  is  consummated  by  these  artificial  means  with  the  train  of  evils 
that  follow  this  departure  from  natural  physiological  law  is  what  I 
would  emphasize. 

Because  a  patient  or  her  friends  insist  that  something  be  done  is  no 
valid  indication  for  harmful  practice.  It  is  our  duty  to  protect  our 
patient's  health  and  happiness.  Reputation,  pleasing  friends,  making 
a  brilliant  display  of  our  activity,  the  saving  of  valuable  time  for  rest 
or  profit,  are  none  of  them  valid  excuses  for  unnecessarily  hastening 
this  process  to  the  ultimate  detriment  of  those  who  rely  upon  our  skill, 
our  knowledge,  and  our  candor  in  this  hour  of  woman's  greatest  pain 
and  peril. 


TRANSACTIONS. 


CLINICAL  SOCIETY  OF  THE  NEW  YORK  POLYCLINIC. 


STATED  MEETING,  APRIL  2,  1906. 

The  President,  JOHN  J.  MacPHEE,  M.  D.,  in  the  Chair. 
Reported  by  FREDERICK  C.  KELLER.  M.  D.,  Secretary. 

REPORTS  OF  CASES. 

TUBERCULOSIS  OF  THE  CARPUS. 

Doctor  Victor  C.  Pedersen  :  I  wish  to  present  this  patient,  a 
young  woman  who  has  suffered  from  tuberculosis  of  the  wrist  for 
many  years.  Several  years  ago  a  palmar  operation  was  performed  in 
a  small  town  up  the  state,  but  there  are  no  evidences  that  tuberculosis 
ever  existed  in  the  hand.  Two  years  ago  the  wrist  was  operated  on, 
a  median  incision  being  made,  and  a  year  ago  two  lateral  incisions  were 
made.  The  wrist  is  now  free  from  pain,  and  except  for  the  ankylosis 
of  the  joints  which  followed  the  first  operation,  there  is  no  difficulty 
in  using  the  wrist.  In  dealing  with  tuberculosis  of  the  wrist,  an  oper- 
ator often  forgets  the  diverticulum  of  synovial  tissue  which  passes 
upward  between  the  radius  and  the  ulna.  At  the  last  operation  per- 
formed upon  this  patient,  it  was  at  this  point  that  the  first  foci  of 
tuberculosis  was  found.  The  largest  synovial  pouch  passes  forward 
between  the  surfaces  of  the  metacarpal  bones,  and  here  was  found  the 


CLINICAL  SOCIETY.  215 

second  foci.  Both  foci  were  removed  and  the  patient  recovered.  As 
a  matter  of  precaution,  she  is  wearing  a  metal  splint  while  performing 
her  household  duties.  The  ankylosis  of  the  fingers  is  the  result  of  the 
operation  performed  four  years  ago,  and  nothing  seems  ot  correct  it. 

GUMMA  OF  THE  FRONTAL  BONE, 

Doctor  Pedersen  :  I  also  wish  to  present  this  patient.  I  first  saw 
this  man  last  summer,  eight  weeks  after  he  had  received  a  violent  blow 
on  the  head.  At  that  time  there  was  a  tumor,  which  was  supposed  to 
be  an  adenoma,  partly  chancroidal,  partly  syphilitic.  It  traveled  down 
under  the  skin,  down  into  the  fatty  tissue,  eating  out  large  masses  of 
the  tissue,  and  finally  was  stopped  by  bromidia  water.  Soon  after  the 
lesion  on  the  head  broke  and  took  on  the  characteristics  of  a  specific 
lesion  and  was  dressed  surgically.  There  seemed  to  be  a  fissure  in 
the  skull,  which  had  been  previously  treated,  and  exfoliation  of  the 
bone  took  place.  There  was  no  temperature  except  that  which  would 
naturally  accompany  anemia.  At  one  time  the  lesion  was  thought  to 
be  tubercular,  but  recovery  under  specific  treatment  seemed  to  confirm 
the  diagnosis  of  gumma  with  profound  anemia. 

DESTRUCTION  OF  TISSUE  AND  NAILS  OF  FOOT, 

Doctor  Pedersen  :  I  will  also  present  another  patient,  who  came 
to  the  House  of  Relief  two  weeks  ago,  having  been  discharged  from 
one  of  the  city  hospitals.  The  nails  of  the  left  foot  and  the  tissue  sur- 
rounding them  showed  evidence  of  great  destruction,  and  there  was  a 
great  deal  of  pus.  The  interesting  question  was  whether  to  apply  blue 
ointment  or  a  wet  dressing.  The  patient's  conditions  of  life  made  it 
impossible  for  him  to  obtain  any  benefit  from  a  wet  dressing,  so  blue 
ointment  was  used,  with  beneficial  results.  The  foot  presented  an 
appearance  very  similar  to  nephritis,  but  the  other  foot  is  not  at  all 
swollen. 

VARICOSE  VEINS, 

Doctor  Alexander  Lyle  :  I  desire  to  present  this  patient,  a  man, 
forty-eight  years  of  age,  who  suffered  from  scarlet  fever  and  whooping- 
cough  as  a  child,  and  from  typhoid  fever  when  twenty-eight  years  of 
age.  He  is  a  heavy  smoker  and  beer  drinker.  His  present  trouble 
dates  back  twenty  years  to  swelling  of  the  ankles.  The  veins  of  the 
right  leg  ulcerated  several  years  ago,  and  a  diagnosis  of  varicose  veins 
was  made.  The  ulcers  are  very  large  in  both  legs,  but  cause  the 
patient  no  discomfort.  I  am  of  the  opinion  that  at  the  time  of  the 
typhoid  a  thrombus  had  formed  in  the  injured  vena  cava,  and  the 
superficial  veins  had  taken  up  the  circulation.  No  abdominal  tumor 
can  be  located,  and  the  veins  all  originate  above  the  brim  of  the  pelvis. 

NEPHRECTOMY. 

Doctor  F.  C.  Yeoman  :  I  wish  to  report  the  case  of  a  man,  aged 
fifty-six,  who  has  been  a  heavy  consumer  of  alcohol.  About  seven 
months  previous  to  operation  he  was  seized  with  a  severe  pain  in  the 


216  ORIGINAL  ARTICLES. 

right  groin,  shooting  downward  to  the  groin  and  corona  glandis,  and 
the  next  day  passed  blood  clots  in  his  urine,  but  never  passed  any 
gravel  to  his  knowledge.  During  the  next  three  months  he  had 
attacks  resembling  renal  colic  at  intervals  of  from  two  to  five  weeks, 
passing  clots  but  no  stones.  During  the  past  two  months  he  had  suf- 
fered severe  intermittent  pain  during  the  night,  beginning  in  the  hypo- 
chondrium  and  extending  over  to  the  midline;  also  intermittent  pain 
referred  to  the  knees,  more  marked  on  the  right  side.  The  urine  of 
late  has  been  free  from  albumin  and  never  showed  any  crystals.  The 
patient's  strength  gradually  diminished  and  he  lost  about  forty-five 
pounds  in  weight.  No  tumor  could  be  felt  seven  months  ago,  but  dur- 
ing the  past  three  months  a  mass  gradually  increasing  in  size  has  occu- 
pied the  right  hypochondrium.  Patient  would  not  permit  cystoscopy. 
He  was  admitted  to  the  Polyclinic  Hospital  February  15,  demanding 
operation  for  the  relief  of  intolerable  pain,  although  he  had  refused  all 
previous  suggestic^s  of  surgical  interference.  His  lungs,  on  physical 
examination,  were  found  to  be  normal ;  heart-sounds  soft,  no  murmur ; 
radials  moderately  thickened.  The  abdomen  was  relaxed  and  the  upper 
limit  of  liver  dullness  diminished  one  intercostal  space.  The  right 
hypochondrium  showed  a  tumor  ovoid  below,  descending  on  deep 
inspiration  to  a  position  opposite  the  umbilicus.  On  pressure  it  took 
the  position  occupied  by  the  normal  kidney.  Blood  examination 
showed  a  white  count  of  eight  thousand,  hemoglobin,  one  hundred  per 
cent. 

A  right  nephrectomy  was  done  on  February  20.  The  operation 
was  difficult,  as  the  kidney  was  about  three  times  the  normal  size,  cov- 
ered with  a  network  of  veins,  and  adherent  on  all  sides.  The  wound 
was  closed,  except  for  cigarette  drains  at  angles.  The  time  of  opera- 
tion was  one  and  one-half  hours,  and  the  patient  rallied  fairly  well; 
but  the  following  two  days  there  was  almost  total  suppression  of 
urine,  only  two  ounces  being  secreted.  Thereafter  his  condition 
improved,  and  he  secreted  about  the  same  amount  and  character  of 
urine  as  before  the  operation;  but  at  the  end  of  a  week  he  began  to 
fail,  and  died  on  the  eighth  day.  Autopsy  was  refused,  and  thus  the 
opportunity  of  discovering  if  metastases  had  occurred  was  lost. 

A  cursory  review  of  the  reported  cases  of  hypernephroma  warrants 
the  following  tentative  conclusions:  Metastases  is  the  rule,  especially 
to  the  liver,  lungs  and  bones.  These  tumors  have  a  tendency  to  spread 
and  involve  veins,  but  no  lymphatics.  The  renal  brim  is  usually 
involved,  and  sometimes  the  cava,  but  does  not  obstruct  sufficiently  to 
cause  edema  of  the  extremities.  In  a  few  cases  the  growth  long 
remains  local  and  can  be  successfully  removed.  Clinically,  the  symp- 
tom that  may  be  of  diagnostic  value  is  bleeding  and  its  results.  Tumor 
and  pain  are  present  as  in  several  other  renal  affections.  Periodic 
attacks  of  hemorrhage,  with  frequency  of  micturition,  often  with  pas- 
sage of  clots,  seem  characteristic.  These  clots  sometimes  block  the 
ureter,  cause  diminished  urine,  and  the  pain  is  referred  to  the  corona 


CLINICAL  SOCIETY.  217 

glandis.  Between  the  attacks  of  bleeding  there  is  fairly  constant  pain 
in  the  back.  A  fresh  hemorrhage  relieves  the  pain,  thus  contrasting 
with  pain  and  bleeding  connected  with  the  passage  of  stone. 

PATHOLOGIC  SPECIMENS. 

Professor  J.  H.  Larkin,  of  Columbia  University :  I  shall  present 
some  pathologic  specimens  of  great  interest  and  give  the  history  of 
each,  insofar  as  I  have  been  able  to  obtain  it.  The  first  are  of  diseased 
appendages,  a  field  of  surgical  research  which  is  becoming  more  and 
more  important.  Until  a  few  years  ago  it  was  supposed  that  lesions  of 
the  pancreas,  as  found  at  postmortem  examinations,  were  fairly  well 
understood,  although  little  was  known  of  the  etiologic  significance; 
but  now  pathologists  are  able  to  show  the  causative  factor.  Its  close 
relationship  to  cholelithiasis  and  other  diseases  of  the  intestinal  tract 
has  been  understood  for  some  time.  The  clinical  histories  in  these 
cases  are  very  similar.  There  is  usually  a  severe  onset  of  gastric  pain 
that  at  times  is  almost  diagnostic  to  the  surgeon  of  appendicitis  or 
intestinal  obstruction,  apd  many  patients  have  been  operated  on  for  one 
or  the  other  of  these  conditions.  In  the  majority  of  cases,  stone  in 
the  ampulla  duct  has  been  a  very  common  factor.  The  specimen  which 
I  present  is  mounted  so  as  to  preserve  its  normal  color.  On  the  right 
side  is  a  portion  of  the  duct  and  on  the  left  a  portion  of  the  pancreas. 
It  is  presumed  that  one  or  more  stones  had  been  passed  in  this  case, 
because  of  the  immense  dilatation  of  the  common  duct.  The  lesion  is 
easily  explained,  and  experiments  have  reproduced  exactly  the  same 
condition.  The  stone  passes  down  into  the  common  duct  and  is 
impacted  at  Bardes'  ampulla,  and  this  leaves  a  continuous  passage  from 
the  common  duct  to  the  ampulla,  and  the  bile,  instead  of  going  down, 
is  sidetracked  and  goes  directly  into  the  pancreas,  and  this  produces 
hemorrhagic  pancreatitis.  This  can  be  reproduced  by  putting  bile  into 
the  pancreatic  duct,  or  a  solution  of  hydrochloric  acid  will  produce  the 
same  result. 

The  next  specimen  shows  the  connection  of  the  pancreas  with  the 
duct,  and  also  shows  the  gall-bladder  with  an  immense  amount  of 
stone.  Of  the  several  interesting  brain  specimens  which  I  present,  no 
clinical  histories  could  be  .obtained.  One  specimen  is  from  a  patient 
who  had  been  under  observation  for  some  time,  and  whose  condition 
had  been  diagnosed  as  cerebral  abscess.  The  specimen  shows  one  side 
of  the  brain,  with  the  cerebellum  and  one  cubic  centimeter  of  hemor- 
rhagic blood  which  was  removed  at  time  of  operation. 

EXHIBITION  OF  INSTRUMENTS, 

Doctor  J.  E.  Fuld  :  I  wish  to  present  this  intestinal  depressor.  I 
devised  it  for  the  purpose  of  depressing  the  intestines  to  prevent  them 
from  extruding  into  the  abdominal  wound  and  interfering  with  the 
operator.  Gauze  pads  are  usually  inserted  to  overcome  this  difficulty. 
The  instrument  has  proved  of  value  in  pushing  aside  not  only  the 
intestines,  but  the  other  abdominal  contents  as  well,  thus  affording  the 


218  ORIGINAL  ABSTRACTS. 

Operator  a  full  view  of  the  area  to  be  inspected.  The  instrument  is  of 
polished  steel,  and  shaped  something  like  the  ordinary  glass  tcfigue 
depressor,  being  eight  inches  long,  one  and  one-half  inches  wide  at 
one  end  and  three-quarters  of  an  inch  wide  at  the  other. 


ORIGINAL  ABSTRACTS. 


MEDICINE. 

By  GEORGK  dock,  A.M.,  M.  D.,  D.Sc.  Ann  Arbor,  Michigan. 

PKOPB8SOK  OF   MBOtCINB  IN  TMB  UmVUISmr  OW  MICHIGAN. 

AND 

DAVID  MURRAY  COWIE,  M.  D.,  Ann  Arbor,  Michigan. 


COURVOISIER'S  LAW:  ITS   VALUE  IN   THE   DIFFEREN- 
TIAL DIAGNOSIS  OF  OBSTRUCTIVE  JAUNDICE. 

MoYNiHAN,  in  the  May  issue  of  the  Edinburgh  Medical  Journal, 
contributes  an  article  "On  the  Violation  of  Courvoisier's  Law,"  from 
which  I  abstract  and  rearrange  what  seem  to  be  the  most  important 
points. 

The  Law. — **In  cases  of  chronic  jaundice  due  to  obstruction  of  the 
common  bile  duct,  a  contraction  of  the  gall-bladder  signifies  that  the 
obstruction  is  due  to  stone;  a  dilatation  of  the  gall-bladder,  that  the 
obstruction  is  due  to  causes  other  than  stone." 

Courvoisier's  explanation  of  the  contraction  or  sclerosis  of  the  gall- 
bladder is  that  stones  had  been  present  in  the  gall-bladder  for  long 
periods;  that  their  presence  had  caused  recurring  attacks  of  cholecys- 
titis, and  that,  as  a  result,  the  gall-bladder  walls  had  become  thickened 
and  fibrous.  The  gall-bladder  so  affected,  became  by  degrees  more  and 
more  shrunken,  and  at  last  was  represented  by  a  shrivelled  mass  of 
fibrous  tissue,  its  cavity  was  greatly  reduced  in  size,  or  almost  oblit- 
erated, and  the  shrunken  dense  adhesions  hid  it  from  sight.  Oft 
repeated  attacks  of  cholecystitis  and  peritonitis  resulted  in  cicatricial 
compression  and  cramping  of  the  gall-bladder. 

Confirmation  of  the  law  has  been  made  by  Ferrier  of  France,  Mayo 
Robson  of  England,  and  A.  Cabot  in  this  country.  Moynihan  cites  a 
few  cases  which  are  directly  in  violation  of  Courvoisier's  law,  but  calls 
attention  to  the  fact  that  Courvoisier  himself  recognized  that  the  law 
may  sometimes  be  flagrantly  infringed,  and  agrees  with  those  just 
mentioned  that  in  the  great  majority  of  cases  that  came  under  his  own 
observation,  the  law  has  proved  to  be  correct,  but  like  all  other  laws  is 
capable  of  infraction. 

Moynihan  sums  up  his  short  but  very  comprehensive  paper  by 


J 


VARICOSE  VEINS.  219 

giving  the  following  chief  circumstances  in  which  the  law  may  be 
violated : 

(i)  Where  there  is  a  stone  or  a  stricture  in  the  cystic  duct  causing 
hydrops  or  empyema,  together  with  the  acute  impaction  of  a  stone  in 
the  common  duct. 

(2)  Where  there  is  a  stone  in  the  cystic  duct  pressing  upon  the 
common  duct. 

(3)  Where  there  is  distension  of  the  gall-bladder  by  an  acute 
inflammatory  process,  with  obstruction  of  the  common  duct  by  stone. 

(4)  Where  there  is  chronic  induration  of  the  head  of  the  pan- 
creas, with  a  stone  in  the  common  duct. 

(5)  Where  there  is  malignant  disease  of  the  common  duct  at  any^ 
part  of  its  course,  or  cancer  of  the  head  of  the  pancreas,  and  a  chronic 
sclerosing  cholecystitis. 

The  validity  of  the  law  is  established  in  at  least  ninety  per  cent  of 
the  cases  in  practice. 

The  value  of  the  paper  is  in  its  suggestion  for  more  careful  differ- 
entiation of  cases  presenting  the  symptom  of  obstructive  jaundice. 

D.  M.  c. 


SURGERY. 

By  frank  BANGHART  WALKER,  Ph.  B.,  M.  D.,  Detroit.  Michigan. 
rmovBStoM  or  sukgbkt  and  opskativb  sukobrt  in  thb  dbtkoit  porroKADUATB  SCHOOL  OF  mbdicinb; 

ADJUNCT  PKOFBSSOR  OF  OPBSATIVB  SURGBRY  IN  THB  DBTIIOIT  COLLBGB  OP  MBOICINB. 

AND 

CYRENUS  GARRITT  DARLING,  M.  D.,  Ann  Arbor,  Michigan. 

CLINICAL  PROFBSaOB  OF  SUB6BKT  IN  THB  VNIVICUrrT  OF  MICHIGAN. 


TREATMENT  OF  VARICOSE  VEINS. 

Charles  H.  Mayo,  M.  D.,  of  Rochester,  Minnesota,  in  Surgery, 
Gynecology  and  Obstetrics,  April,  1906.  Of  the  many  operations 
advised  for  the  relief  of  varicose  veins  no  one  is  suited  to  all  cases. 
Not  only  the  superficial  veins  produce  the  symptoms  but  the  deeper 
veins  are  probably  enlarged.  The  long  or  internal  and  the  short  or 
external  sapheni  veins  are  the  ones  usually  affected.  These  connect 
at  the  knee  and  the  internal  also  connects  with  the  deeper  veins  at  this 
point.  The  internal  extends  from  the  saphenous  opening  to  the  ankle 
and  joins  the  external  saphenous  through  the  dorsal  vein  of  the  foot. 
These  veins  contain  a  number  of  valves  which  aid  in  separating  the 
blood  column.  The  internal  vein  is  accompanied  by  the  internal 
saphenous  nerve,  and  the  external  vein  by  the  external  saphenous  nerve. 

The  cause  of  varicose  veins  is  difficult,  in  many  cases,  to  under- 
stand. In  some  it  may  mean  congenital  defect  in  the  vein  walls,  valves, 
or  enervation.  In  some  cases  pregnancy  is  given  as  a  cause  and  in 
others  pressure  of  tumors  or  injury.  Vocation  oftentimes  increases 
the  condition  and  symptoms.  The  condition  may  begin  as  early  as 
twenty  years,  but  many  years  may  elapse  before  disabling  symptoms 


220  ORIGINAL  ABSTRACTS. 

may  appear.  The  symptoms,  which  are  well  known,  consist  of  ^fullness 
or  weight  of  the  leg  with  edema  and  pain.  This  may  lead  to  pruritus 
or  eczema.  Local  hemorrhages  are  frequent  and  may  lead  to  pigmen- 
tation and  discoloration  of  the  skin ;  or,  the  tissues  may  break  down, 
forming  ulcers. 

The  so-called  Trendelenburg  phenomenon  is  tested  by  lifting  the 
leg  while  the  patient  is  lying  down,  and  when  the  veins  are  empty  the 
long  saphenous  is  compressed  above.  The  patient  now  stands  erect 
and  the  pressure  is  removed  and  if  the  veins  fill  from  below  the  valves 
are  intact;  and  if  the  waves  of  blood  descend  the  valves  are  useless. 
A  few  cases  may  be  relieved  by  a  change  of  vocation  or  climate,  others 
are  required  to  wear  elastic  supports  such  as  bandages  or  stockings. 
Operative  measures  for  relief  are  as  old  as  the  history  of  surgery  and 
include  ignipuncture  with  Paquelin  or  electro-cautery,  cutaneous  and 
subcutaneous  ligation  which  are  now  seldom  used,  injections  of  irri- 
tants in  and  about  the  veins,  multiple  ligation  and  excisions,  multiple 
incisions  with  torsion,  removal,  or  Trendelenburg's  operation  which 
consists  in  ligating  and  removing  a  short  section  from  the  upper  por- 
tion of  the  long  saphenous.  The  more  recent  methods  are  subcu- 
taneous removal  in  suitable  cases  and  nerve  stretching.  To  test  the 
advisability  of  operation  an  elastic  bandage  is  applied  from  the  foot  to 
above  the  knee.  If  this  bandage  can  be  worn  with  comfort  the  oper- 
ation should  give  relief  as  the  pressure  shows  that  superficial  vessels 
are  not  necessary  to  circulation  of  the  limb. 

The  writer  reports  one  hundred  eighty-five  cases  operated  upon, 
many  times  operation  including  both  limbs.  A  number  of  changes  or 
modifications  have  been  made  in  the  operation.  To  aid  in  the  work  a 
ring  vein  enucleator  and  a  pair  of  forceps,  the  end  of  which  forms  a 
ring  when  closed,  have  been  invented.  This  operation  is  described  as 
follows : 

"The  vein  is  sought  for  and  severed  in  the  upper  third  of  the  thigh. 
The  proximal  end  is  ligated.  The  lower  end  is  passed  through  the 
ring  of  the  enucleator  or  placed  in  the  ring  of  the  forceps,  and  clamps 
are  placed  on  the  end  of  the  vein.  By  a  gentle  pushing  force,  the  vein 
being  held  to  make  tension  and  the  tissues  steadied  on  either  side  by 
an  assistant,  the  ring  or  forceps  is  pushed  down  the  vessel  for  six  or 
eight  inches,  tearing  off  the  lateral  branches,  when  the  point  of  the 
instrument  is  forced  against  the  skin  from  beneath  and  a  small  incision 
is  made  to  the  ring  or  forceps,  which  is  pushed  through  the  opening, 
holding  the  vein  like  a  thread  in  a  needle's  eye.  The  vein-loop  is 
drawn  out  of  the  opening  and  also  from  the  instrument,  which  is 
removed,  rethreaded  on  the  vein,  and  is  pushed  down  to  a  lower  point, 
where  a  small  incision  is  again  made  and  the  process  of  removal 
repeated.  The  small  lateral  branches  are  torn  off,  and,  as  a  rule, 
have  enough  muscle  structure  to  close  themselves.  Should  the  main 
venous  trunk  break,  a  new  incision  is  made  below  the  knee,  the  vein 


INFLUENCE  OF  FEEDING  ON  INFANT  MORTALITY.  221 

exposed  and  divided,  and  the  enucleation  made  in  both  directions  from 
this  point.  Below  the  knee  the  branches  are  larger  and  the  vein  is 
more  adherent,  being  more  superficial,  so  that  a  shorter  distance  must 
be  travelled.  If  it  is  found  that  calcareous  deposits,  sacculations,  or 
extreme  weakness  of  the  walls  render  the  case  unsuited  to  the  enucle- 
ation method,  and  this  occurs  in  about  ten  per  cent  of  the  cases,  the 
principle  of  operation  should  then  be  changed  to  an  open  method, 
undermining  only  the  section  by  the  knee.  Hemorrhage  is  avoided, 
first  by  position.  An  ordinary  gynecologic  standard  is  placed  in 
position,  and  the  leg  raised  in  straight  or  extended  position  and  sup- 
ported by  the  ankle.  The  position  renders  the  limb  partially  bloodless, 
and  also  secures  elevation  and  accessibility  of  the  field  of  operation. 
Should  any  branches  cause  more  than  ordinary  hemorrhage,  it  can  be 
checked  by  a  pressure-pad  held  against  the  skin  over  the  region  from 
which  the  veins  were  removed,  or  by  small  packs,  which  are  left  for  a 
few  minutes  in  the  incision  from  which  it  arises." 

When  ulcers  are  present  the  ulcerated  area  is  excised  and  skin- 
grafted.  Eczematous  areas  are  painted  with  compound  tincture  of 
benzoin  or  an  acetic  solution  of  gutta-percha  which  acts  as  an  antisep- 
tic varnish.  The  leg  is  kept  elevated  for  twelve  days.  Recurrence 
may  come  from  widening  of  collateral  veins,  formation  of  new  veins  or, 
as  is  claimed,  from  the  regeneration  of  the  saphenous  itself. 

The  dangers  from  operation  are  pulmonary'  embolism.  Sepsis  is 
rare,  although  a  serious  possibility,  and  difficult  to  guard  against  in 
some  cases  with  ulcer  and  eczema. 


PEDIATRICS. 

By  ARTHUR  DAVID  HOLMES,  M.  D.,C.  M.,  Detroit,  Michigan. 


INFLUENCE  OF  FEEDING  ON  INFANT  MORTALITY. 

HowARTH  (Lancet,  July  22,  1905),  having  investigated  this  ques- 
tion in  eight  thousand  three  hundred  forty-two  children,  says  the  death- 
rate  among  the  hand-fed  was  nearly  three  times  as  high  as  that  among 
the  breast-fed  and  twice  that  of  children  reared  on  mixed  feeding. 
Among  children  who  were  first  breast-fed  and  subsequently  hand-fed 
the  death-rate  was  not  so  high  as  among  the  purely  hand^fed,  showing 
the  advantage  accruing  to  children  who  have  natural  food  supple- 
mented by  artificial,  rather  than  an  entire  supply  of  the  latter.  Children 
fed  on  condensed  milk  show  a  very  high  mortality,  and  children  reared 
on  bread,  rusks,  arrowroot  and  other  farinaceous  foods  come  next. 
His  deductions  are  as  follows :  The  use  of  sweetened  condensed  milk, 
either  whole  or  skimmed,  should  invariably  be  discouraged,  and  whole 
unsweetened  condensed  milk  only  should  be  permitted  where  one  is 
satisfied  that  the  milk  is  being  used  with  a  proper  degree  of  dilution  and 
.with  the  necessary  additions,  as  in  the  case  of  modified  cow's  milk; 


222  ORIGINAL  ABSTRACTS. 

also  that  since  the  death-rate  among  children  reared  on  patent  foods 
is,  on  the  average,  higher  than  among  those  fed  on  diluted  cow's  milk, 
every  attempt  should  be  made  to  encourage  parents  to  use  the  latter 
food  and  to  educate  them  to  an  appreciation  of  the  necessity  for  the 
additions  to,  and  the  dilution  of,  cow's  milk  to  render  it  suitable  for 
infant's  food.  The  addition  of  patent  foods  to  the  dietary  of  very  young 
infants  is  unnecessary,  sometimes  dangerous  and  always  expensive. 
Furthermore,  it  must  not  be  forgotten  that  the  risks  to  which  hand-fed 
children  are  exposed  are  considerably  minimized  by  mixed  feeding  and 
that  therefore  every  mother  who  is  unable  fully  to  satisfy  her  infant 
should  be  encouraged  to  continue  to  feed  her  child  and  to  supplement 
any  deficiency  by  means  of  artificial  foods,  and  that  only  in  ease  of 
absolute  necessity  should  resort  be  had  to  artificial  feeding  alone. 


OPHTHALMOLOGY. 

By  WALTER  ROBERT  PARKER.  B.  S..  M.  D. 

rKOFBSSOIt  OF   OPUTUALHOLOGT  IN  THB  UMIVBKSITT  OF  MICHIGAN. 


HOW  A  LIGHT  SHOULD  BE  PLACED  FOR  READING. 

Cravath  and  Lansing,  in  The  Electrical  World,  of  January  6. 
The  general  lighting  of  small  living  rooms  and  parlors,  together  with 
the  location  of  lights  for  reading  in  such  rooms,  is  discussed,  with 
criticism  of  special  cases.  The  writers  note  at  the  outset  that  the 
general  lighting  of  a  small  living  room  and  the  provision  for  reading 
lights  are  so  closely  connected  that  they  must  necessarily  be  considered 
together.     They  write : 

"The  reading  light  is  the  one  that  is  likely  to  be  used  constantly 
and  has  so  much  to  do  with  the  comfort  and  eyesight  of  members  of  the 
family  that  it  needs  earnest  consideration.  There  are  three  common 
ways  of  obtaining  a  reading  light.  One  way  is  to  illuminate  the 
whole  room  so  brightly  that  reading  is  easy  in  any  part  of  it.  This  is 
usually  undesirable  for  two  reasons:  One  is  that  the  eye  is  likely  to 
tire  more  quickly  in  a  room  so  brightly  illuminated  in  all  corners  than 
it  would  be  if  it  had  an  opportunity  to  rest  by  looking  from  the  lighter 
to  the  darker  parts  of  the  room  occasionally.  The  cost  of  lighting  a 
room  so  brilliantly  as  this  makes  it  out  of  the  question  in  the  majority 
of  .rooms.  We  will,  therefore,  leave  out  of  consideration  this  method 
of  securing  a  reading  light  and  consider  the  second  and  third  methods. 
The  second  method  is  to  use  a  lamp  placed  near  the  reader  and  fitted 
with  a  globe  or  reflector  which  will  concentrate  nearly  all  the  light  on 
the  book  or  paper.  If  we  do  this,  the  reading  lamp  is  likely  to  be  of 
little  value  in  the  general  lighting  of  the  room  and  we  will  have  to 
add  other  lights  besides  the  reading  lamp  if  the  greater  part  of  the 
room  is  not  to  be  in  comparative  darkness.  The  third  method,  which 
is  the  one  usually  to  be  preferred  where  the  greatest  economy  is  an 


LOCATION  OF  LIGHT  FOR  READING.  223 

object,  is  to  use  the  same  light  both  for  reading  and  for  the  general 
lighting  of  the  room  by  equipping  the  reading  light  with  a  globe  or 
reflector  which  will  concentrate  a  considerable  portion  of  its  light 
within  the  area  in  which  it  is  desired  to  read  and  at  the  same  time 
allow  enough  light  to  radiate  in  all  directions  to  give  fairly  good  illu- 
mination over  the  rest  of  the  room." 

The  popular  impression  that  a  portable  table  lamp  is  better  adapted 
to  reading  than  a  lamp  on  a  chandelier  or  bracket  is  regarded  by  the 
authors  as  a  misconception,  such  table  lamps  being  merely  an  inheri- 
tance from  the  days  of  the  candle  and  oil  lamps.     They  say : 

"With  electric  light,  usually  much  more  satisfactory  results  can  be 
obtained  with  a  properly  equipped  reading  light  on  or  suspended  from 
the  chandelier  or  on  a  bracket  on  one  of  the  side  walls.  The  reason 
for  this  is  that  it  is  impossible  with  a  table  lamp  to  secure  a  reflector 
which  will  throw  as  large  a  proportion  of  the  light  where  it  is  needed 
for  reading  purposes  as  can  be  obtained  from  the  proper  reflectors  on 
chandeliers  and  brackets.  Most  of  the  electric  portable  stand  lamps 
throw  the  greater  part  of  the  light  down  on  the  table  around  the  base 
of  the  lamp,  so  that  the  readers  sitting  around  the  table  get  only  a  small 
percentage  of  the  light.  If  the  portable  stand  lamp  is  used  on  a  library 
table  where  the  readers  place  their  bodes  on  the  table  each  side  of  the 
lamp  its  use  is  permissible,  but  such  is  not  the  usual  condition. 

"There  is  also  considerable  misconception  as  to  the  comparative 
distance  from  the  reader  of  a  lamp  located  six  feet  above  the  floor  on  a 
chandelier  as  against  a  lamp  located  on  a  table.  The  average  person 
who  has  never  measured  these  distances  is  under  the  impression  that 
the  lamp  on  the  reading  table  is  much  nearer.  As  a  matter  of  fact,  the 
distances  are  nearly  the  same.  There  is  really  for  the  majority  of 
cases  only  about  one  thing  to  be  said  in  favor  of  an  electric  table  lamp 
for  reading  as  against  a  properly  equipped  lamp  on  a  chandelier  or 
bracket.  This  is  that  with  the  table  lamp  it  is  not  as  likely  that  a 
reader  will  get  the  regular  reflection  commonly  known  as  "glare"  from 
a  page  of  white  paper  because  the  light  comes  so  much  from  one  side. 
In  reading  underneath  a  lamp  on  a  chandelier  or  bracket  the  reader 
must  turn  the  page  at  such  an  angle  that  he  does  not  receive  this  glare 
from  the  paper.  This  is  easily  done,  but  many  people  undoubtedly 
suffer  from  this  without  knowing  what  is  the  trouble  or  taking  pains 
to  find  out.  Since  this  glare  of  regular  reflection  is  likely  to  be  more 
pronounced  with  electric  light  than  with  kerosene  lamps,  it  is  probable 
that  this  is  responsible  for  the  preference  that  some  people  have  for 
oil  reading  lamps,  even  though  electric  light  is  available  in  the  rest  of 
the  house." 

In  advocating  the  use  of  reading  lamps  placed  on  chandeliers  and 
brackets  rather  than  table  lamps,  the  authors  disclaim  a  desire  to  advise 
trying  to  read  with  chandeliers  arranged  for  the  general  illumination 
of  the  room.  Chandeliers  to  be  used  for  reading  lights  should  be 
especially  equipped  for  the  purpose. 


224  ORIGINAL  ABSTRACTS. 

OTOLOGY. 


By  R.  bishop  CANFIELD,  A.  B..  M.  D.,  Ann  Arbor.  Michigan. 

PKOrSSSOB  OF  OTOLARYNGOLOGY  IN  THB  UNIVUSITY  OF  MICHIGAN. 

AND 

WILLIAM  ROBINSON  LYMAN,  A.  B.,  M.  D.,  Ann  Arbor,  Michigan. 

OBMONSTKATOS  OF  OTOLAKYNGOLOGY  IN  THB  UNIYBRSITY  OF  MICHIGAN. 


A  CASE  OF  ACUTE  MIDDLE  EAR  SUPPURATION,  COM- 
PLICATED BY  LABYRINTHINE  FISTULA  AND 
PARALYSIS  OF  THE  ABDUCENS  NERVE. 

HiLL  Hastings,  M.  D.,  in  Archives  of  Otology,  Volume  XXXV, 
Number  I.  Twenty  cases  of  paralysis  of  the  abducens  nerve  have 
been  reported.  This  case  presented  at  re-operation  a  fistula  through 
the  inner  tympanic  wall  as  the  probable  avenue  of  extension  of  the 
infection.  Gradenigo  concluded  that  this  syndrome  of  clinical  symp- 
toms is  the  result  of  a  circumscribed  simple  serous  leptomeningitis 
localized  about  the  tip  of  the  pyramid  and  caused  by  the  diffusion 
of  the  infection  in  the  tympanum  generally  through  the  tegmen 
tympani. 

The  patient  was  a  male,  twenty-two  years  old,  who  had  an  acute 
ear  trouble  following  a  head  cold.  The  ear  showed  some  purulent 
discharge,  sagging  of  the  posterior  superior  canal  and  an  inflamed 
bulging  membrane  with  a  small  perforation.  Moderate  mastoid  ten- 
derness, chiefly  over  antrum  and  tip.  Some  tinnitis  but  no  dizziness  or 
other  symptoms.  A  free  incision  was  made  in  the  membrane.  Three 
days  later  the  mastoid  operation  was  performed  with  no  findings  of 
especial  interest.  After  operation  discharge  and  pain  continued  and 
gradually  increased  though  the  mastoid  wound  was  clean.  There  was 
some  dizziness  and  marked  tinnitus.  The  membrane  remained  red  and 
bulging  and  was  incised  two  or  three  times  to  offer  better  drainage. 
On  the  twelfth  day  the  patient  complained  of  increased  dizziness  and 
double  vision.  Examination  showed  marked  diplopia  due  to  paralysis 
of  the  abducens.  No  other  motor  or  sensory  disturbance.  As  this 
case  was  an  acute  one  and  the  hearing  had  been  normal  a  radical  opera- 
tion was  deferred.  As  the  paralysis  continued  and  the  pain  and  dizzi- 
ness increased  a  radical  mastoid  operation  was  done  on  the  eleventh  day 
after  the  appearance  of  the  paralysis. 

The  tympanic  cavity  was  found  full  of  granulations  and  pus; 
malleus  and  incus  were  normal.  When  the  cavity  was  cleansed  pus 
could  be  seen  coming  from  the  inner  tympanic  wall  in  the  recess  of 
the  oval  window  apparently  through  that  opening.  The  stapes  was 
not  found.  The  fistula  was  found  to  lead  inward  for  half  a  centi- 
meter before  bony  resistance  was  noticed.  The  opening  was  enlarged 
and  the  fistula  swabbed  out  with  bichloride  solution.  No  other 
necrosis  of  the  tympanum  was  found.  A  Ballance  flap  was  made  and 
sutured  above;  the  posterior  wound  was  left  open.     Facial  twitching 


TREATMENT  ON  MYCOSIS.  225 

occurred  during  the  operation  due  to  injury  to  the  horizontal  portion 
of  the  facial  canal  which  formed  the  upper  rim  of  the  fistula. 

After  the  operation  the  pain  subsided.  The  paralysis  gradually 
passed  off  and  the  diplopia  entirely  disappeared  in  four  weeks.  The 
slight  facial  paralysis  passed  off  within  a  week.  The  discharge  and 
dizziness  soon  disappeared.  The  middle  ear  was  grafted  five  weeks 
later,  the  posterior  wound  closed  and  the  patient  made  a  good  recovery. 

The  peculiar  features  of  this  case  are : 

(i)  The  involvement  of  the  internal  ear  early  in  the  course  of  an 
acute  suppurative  otitis  media. 

(2)  The  avenue  of  infection  was  through  the  oval  window. 

(3)  The  cause  of  the  abducens  paralysis  by  extension  of  the 
infection  to  the  nerve  sheath  through  the  labyrinth  seems  probable  on 
account  of  its  rapid  subsidence  after  drainage  of  the  labyrinth  was 
established. 

(4)  The  prompt  recovery  after  drainage  was  established  suggests 
that  it  was  not  necessary  to  remove  the  inner  tympanic  wall  and  com- 
pletely curet  the  inner  ear. 

(5)  The  conclusion  seems  reasonable  that  the  occurrence  of  abdu- 
cens paralysis  in  acute  suppurative  otitis  media  means  an  inward 
invasion  of  the  infection,  and  when  accompanied  by  the  above  men- 
tioned symptoms  operative  rather  than  palliative  treatment  should  be 
applied  to  the  tympanic  cavity.  R.  b.  c. 


LARYNGOLOGY. 

By  WILLIS  SIDNEY  ANDERSON.  M.  D..  Detroit.  Michigan. 

AaSBTAMT  TO  TMB  CMAIB  OF  LASTMGOLOGT  IN  THE  PBTKOIT  COLLBGB  OF  MBDICINB 


THE  ETIOLOGY  AND  TREATMENT  OF  MYCOSIS  OCCUR- 
RING IN  THE  UPPER  RESPIRATORY  TRACT. 

Under  the  above  title,  Doctor  John  Sendziak,  of  Warsaw  (Annals 
of  Otology,  Rhinology  and  Laryngology,  December,  1905),  gives  an 
exhaustive  review  of  the  subject.  He  states  that  the  following  are 
the  particular  varieties  of  mycoses  met  with  in  the  upper  respiratory 
tract : 

(i)  Mycosis  leptothricia :  causative  agent — leptothrix  bacillus. 

(2)  Mycosis  sarcinica :  causative  agent — ^a  variety  of  the  sarcina. 

(3)  Actinomycosis:  the  causative  agent  being  the  actinomyces. 

(4)  Mycosis  aspergillosis :   caused  by  various  kinds  of  aspergillus. 

(5)  Mycosis  mucorina:  produced  by  certain  varieties  of  mucor. 
This,  according  to  some  authors,  causing  the  so-called  "black-tongue." 

(6)  Mycosis  oidica  (soor)  :  caused  by  the  oidium  albicans. 

The  etiology  of  mycosis  leptothricia  has  not  been  positively  decided. 
There  exists  two  principal  theories:  (a)  The  parasitic,  and  (b)  the 
chdmical  theory.     The  advocates  of  the  first  theory  believe  that  the 


226  ORIGINAL  ABSTRACTS. 

causative  agent  is  the  leptothrix  bacillus,  while  those  who  believe  in 
the  second  theory  hold  that  the  organism  is  merely  incidental  to  chem- 
ical changes  in  the  secretions. 

Mycosis  leptothricia  is  relatively  more  frequent  in  females  than  in 
males.  It  shows  itself  in  the  form  of  pearly  white,  hard  tufts  or  spots 
which  are  situated  in  the  crypts  of  the  faucial  tonsils,  the  lingual  tonsils, 
and  sometimes  seen  in  the  follicles  of  the  posterior  pharyngeal  wall. 
These  tufts  are  strongly  adherent  to  the  adjacent  tissue  and  are  removed 
with  difficulty,  leaving  a  bleeding  surface. 

The  course  of  the  disease  is  chronic,  and  the  symptoms  may  be  few, 
or  none  at  all.  The  most  common  symptoms  are  a  scratching,  pricking, 
burning  sensation  in  the  throat,  accompanied  by  a  disagreeable  sensation 
of  stiffness  and  fullness. 

The  most  satisfactory  treatment  is  the  thorough  use  of  the  curet 
or  the  galvanocautery  to  eradicate  the  disease.  General  tonics  should 
be  given. 

Mycosis  sarcinica  occurs  in  the  upper  respiratory  tract  on  the 
mucous  membranes  of  the  oral  cavity  in  persons  who  suffer  from 
diseases  of  the  lungs,  pneumonia,  bronchiectasis,  gangrene,  and  espe- 
cially in  persons  suffering  from  tuberculosis  or  typhoid.  This  parasite 
is  found  on  the  mucous  membrane  of  the  tongue,  as  well  as  on  the  soft 
palate,  in  whitish  diffuse  masses  similar  to  mould.  This  form  of  myco- 
sis is  of  no  special  importance,  and  general  symptoms  are  lacking. 

-Actinomycosis  is  more  frequent  in  men  than  in  women,  and  usually 
runs  a  chronic  course.  The  disease  is  common  in  cattle,  and  may  be 
transferred  directly  to  man.  The  symptoms  of  actinomycosis  of  the 
upper  respiratory  tract  consist,  in  general,  of  very  violent  pains  in  the 
region  of  the  pathologic  process.  The  disease  is  primarily  located  in 
the  oral  cavity,  on  the  alveolar  process  of  the  lower  jaw,  causing  perios- 
titis alveolaris.  It  may  extend  to  the  pharynx,  producing  great  swell- 
ing in  the  palatopharyngeal  region,  with  whitish-yellow  nodules  iden- 
tical in  appearance  to  follicular  abscess. 

The  prognosis  is  not  favorable,  especially  if  the  internal  organs 
become  affected  by  the  metastatic  processes. 

The  treatment  of  actinomycosis  of  the  upper  respiratory  tract  is 
primarily  surgical  in  nature.  lodid  of  potassium  internally  seems  to 
do  good. 

Mycosis  aspergillina  in  the  upper  respiratory  tract  is  rarely  seen 
The  cause  of  this  is  undoubtedly  due  to  the  peculiarity  of  these  organs. 
Persons  working  in  tanneries,  or  those  dealing  in  leather,  are  predis- 
posed to  this  disease,  as  leather  is  an  excellent  medium  in  which  the 
development  of  the  aspergillus  occurs. 

Mycosis  mucorina  in  the  upper  respiratory  tract  occurs  but  rarely. 
It  appears  in  two  forms:  (a)  Mycosis  dependent  on  the  mucor  corym- 
bifer,  and  (b)  mycosis  depending  on  the  mucor  niger — the  more  usual 
form.     The  second  form,  the  so-called  "black-tongue,"  is  not  a  rare 


SPIROCH.€TA  PALLIDA  IN  SYPHILIS.  227 

condition.  The  clinical  picture  is  a  brown  discoloration,  or  a  hairy- 
black  condition  on  the  posterior  part  of  the  papillae  circumvallatae. 

The  treatment  consists  in  the  scraping  away  of  the  hairy  material, 
as  well  as  the  use  of  alkaline  gargles. 

Mycosis  oidioa  (soor,  thrush)  occurs  usually  in  young  children. 
The  infection  takes  place  from  ingested  objects,  from  nipples,  and  less 
frequently  from  the  air,  or  the  infection  takes  place  through  the  phe- 
nomenon of  partus.  Thrush  occurs  as  small,  round,  white  spots,  with 
small  excavations  in  the  center,  easily  removable  at  first,  later,  as  the 
disease  progresses,  more  adherent.  These  spots  coalesce  irregularly, 
forming  a  sort  of  membrane  of  dirty  color,  the  underlying  mucous 
membrane  being  red  and  swollen. 

Local  cleanliness  and  general  treatment  is  indicated  in  this  disease. 


DERMATOLOGY. 

By  WILLIAM  FLEMING  BREAK  EY.  M.  D.,  Ann  Arbor,  Michigan. 

CLINICAL  rROFBSSOK  OF  DBKMATOLOGT  AND  STmiLOLOGT  IN  THB  UNIVBKSITT  OF  MICHIGAN. 

AND 

JAMES  FLEMING  BREAKEY.  M.D.,  Ann  Arbor,  Michigan. 

ASSISTANT  IN  DBBMATOLOGY  IN  THB  UN1VBB81TY  OF  MICHIGAN. 


SPIROCH^TA  PALLIDA   (SPIRONEMA  PALLIDUM)    IN 

SYPHILIS. 

The  Lancet  of  March  lo  contains  a  symposium  on  the  spirochaetae. 
The  first  article  under  the  above  title  is  concluded  in  the  issue  of  March 
17.  In  this,  Theodore  Shennan  goes  into  the  history  and  literature  of 
the  search  for  the  contagium  of  syphilis  from  the  time  of  the  sixteenth 
century.  His  search  of  the  literature  on  the  spirochaetae  has  been 
thorough.  He  records  the  works  of  Schaudinn  and  Hoffmann,  and 
describes  the  spirochaeta  pallida  and  spirochaeta  refringens,  methods 
of  staining  and  differentiating. 

Spirochaeta  pallida  has  been  found  in  surface  lesions,  indolent 
buboes,  in  blood  obtained  by  splenic  puncture,  in  circulating  blood  in 
secondary  syphilis  and  in  various  lesions  of  the  inherent  syphilitic. 
Levaditi  considers  congenital  syphilis  to  be  a  spirillosis  of  the  newly 
born.  Efforts  to  find  the  spirochaeta  pallida  in  tertiary  lesions  have, 
with  rare  exceptions,  proved  unsuccessful.  In  searching  for  spiro- 
chaetae numerous  preparations  should  be  made  owing  to  their  unequal 
and  irregular  distribution. 

Kiolomenoglou  and  von  Cube  found  and  demonstrated  various 
forms  of  spirochaetae  in  nonspecific  lesions.  Hoffmann  admitted  their 
great  similarity  but  claimed  that  they  could  be  morphologically  or 
tinctorially  distinguished  from  the  pallida.  Hoffmann  states  that 
those  found  in  carcinomata  have  blunt  ends. 

Kraus  and  Prantschoff  found  that  spirochaetae  disappear  from 
excised  tissues  within  six  hours.     This  is  interesting  in  view  of  the 


228  ORIGINAL  ABSTRACTS. 

generally  accepted  clinical  fact  that  syphilitic  virus  removed  from  the 
body  soon  degenerates. 

Levaditi  and  Petresco  found  spirochaetae  readily  and  in  considerable 
numbers  in  the  serum  of  induced  blisters. 

Rona  found  the  spirochaeta  pallida  in  six  out  of  twenty  healthy 
women  and  in  three  out  of  eighteen  healthy  men.  Similar  results  are 
reported  by  others. 

The  syphilitic  virus  cannot  pass  through  a  porcelain  filter. 

Statistics  of  the  findings  of  numerous  authors  are  given. 

Schaudinn  found  spirochaeta  pallida  constantly  in  seventy  cases 
and  in  tertiary  lesions  as  granular  resting  forms. 

Castellani  and  Wellman  have  found  spihochaetae  in  yaws  correspond- 
ing closely  to  the  spirochaeta  pallida. 

Various  spirochaetae  often  much  resembling  the  spirochaeta  pallida 
have  been  found  in  hospital  gangrene,  in  noma,  gangrenous  tonsillitis, 
vaccine  pustule,  carcinomata  and  various  venereal  and  nonvenereal 
conditions  and  in  the  bone  marrow  and  muscular  coat  of  the  small 
intestine  from  cases  of  severe  anemias  and  carcinomatous  lymphangitis. 
These  various  spirochaetae,  as  a  rule,  may  be  differentiated  by  staining. 

Attempts  at  cultivation  have  so  far  been  unsuccessful,      j.  f.  b. 


NEUROLOGY. 

By  DAVID  INGLIS,  M.  D.,  Detroit,  Michigan. 

PKOFKSOR  or  NBKVOVS  AND   MBNTAL  DISSASBS  IN  THE  DBTROIT  COLLBGB  OP  MBOICINB. 

AND 

IRWIN  HOFFMAN  NEFF,  M.  D..  Pontiac.  Michigan. 

ASSISTANT  PHYSICIAN  AT  THE  BASTBPN  MICHIGAN  ASYLUM. 


"THE  MENTAL  SYMPTOMS  OF  CEREBRAL  TUMOR." 

Doctor  Phillips  Coombs  Knapp  cites  {Boston  Medical  and  Sur- 
gical Journal,  April  5,  1906)  the  opinion  of  others  on  the  relation 
and  frequency  of  mental  symptoms  in  brain  tumors,  and  g^ves  his  statis- 
tics, which  have  proved  to  him  that  in  ninety  per  cent  of  all  cases  of  brain 
tumor  mental  symptoms  can  be  noted.  He  reiterates  his  statement  made 
some  years  ago  that  in  every  case  some  mental  change  can  be  found 
by  a  competent  observer  who  has  known  the  patient  before.  In  other 
words :  there  can  be  no  gross  lesion  in  the  brain  without  some  disturb- 
ance, greater  or  less,  in  the  physical  functions.  He,  however,  modifies 
the  dictum  to  this  effect :  that  in  every  case  of  brain  tumor  some  mental 
symptoms  can  properly  be  discovered,  at  least  by  a  competent  observer 
who  has  known  the  patient  intimately  before.  Regarding  the  nature 
of  the  mental  symptoms,  Knapp  says  that  his  investigations  agree  with 
those  of  Schuster.  Schuster's  statistics  are  dependent  upon  a  series  of 
seven  hundred  seventy-five  collected  cases,  and  would  indicate  that 


THERAPEUTICS  OF  LUPULIN.  229 

while  mental  torpor  and  stupor  are  present  in  a  greater  proportion  of 
cases,  specific  psychoses  are  not  infrequently  found.  Thus  of  his 
seven  hundred  seventy-five  collected  cases,  two  hundred  fifteen  showed 
mental  conditions  analogous  to  recognized  forms  of  mental  trouble. 
The  question  of  the  relation  of  the  seat  of  the  tumor  and  the  mental 
symptoms  is  given  considerable  space  by  the  author.  The  statistics  of 
collaborators  are  considered  and  a  reference  table  comprising  all  of 
the  author's  cases  is  given. 

In  conclusion  he  states  that  "in  studying  the  early  development  of 
mental  symptoms  I  have  already  indicated  the  relative  importance  of 
certain  areas  in  the  possible  production  of  such  symptoms ;  but  the  fact 
that  mental  symptoms  m^y  arise  from  a  growth  anywhere  within  the 
cranium,  forces  upon  us  the  conclusion  that  other  factors  beside  the 
location  are  of  importance  in  their  production."  Knapp  is  unable  to 
find  any  relation  between  the  nature  of  the  growth  and  the  form  of 
mental  disturbance.  He  believes,  however,  that  a  rapidly  growing 
tumor  will  more  speedily  cause  mental  symptoms  than  one  of  slow 
growth.  He  also  infers  from  his  study  that  "delirious"  conditions  are 
more  apt  to  occur  in  cases  of  sarcoma.  Attention  is  called  to  the 
resemblance  between  the  mental  symptoms  met  with  in  cases  of  brain 
tumors  to  those  occurring  in  toxic  psychoses. 

The  writer  believes  that  the  cases  under  consideration  reveal  noth- 
ing as  to  the  nature  or  even  the  existence  of  these  toxins,  but  it  seems 
probable  that  while  the  situation  of  the  growth  is  often  of  influence  in 
producing  mental  symptoms,  especially  in  the  early  stages  of  the  dis- 
ease, and  possibly  has  an  influence  upon  the  nature  of  the  symptoms, 
a  combination  of  increased  cranial  pressure  and  the  action  of  the  toxin 
are  of  greater  importance,  and  in  some  cases  may  be  the  only  factor  to 
be  considered  in  the  production  of  such  symptoms.  i.  h.  n. 


THERAPEUTICS. 

By  DELOS  LEONARD  PARKER,  Ph.  B.,  M.  D.,  Detroit,  Michigan. 

LBCTVKBK  ON  MATKRIA  IfBDICA  IN  THB  DBTROIT  COLLBGB  OF  MBDICINB. 


THE  THERAPEUTICS  OF  LUPULIN. 

Doctor  Thomas  F.  Reilly  (The  Journal  of  the  American  Medical 
Association,  April  7,  1906)  discusses  the  therapeutics  of  lupulin  as 
brought  out  by  an  investigation  made  by  himself  and  H.  Stern,  M.  D., 
of  New  York.  At  the  outset  the  statement  is  made  that  the  purpose  of 
the  paper  is  to  bring  into  view  some  of  the  old,  and  also  some  of  the 
new,  properties  of  one  of  the  oldest  agents  in  the  materia  medica. 

Attention  is  called  to  the  circumstance  that  formerly  lupulin  was 
looked  upon  as  almost  a  specific  for  scrofula,  struma  and  the  various 
skin  diseases. 


230  ORIGINAL  ABSTRACTS. 

Lupulin  is  derived  in  the  form  of  scales  from  the  hop  plant.  These 
scales  contain  lupulinic  and  humilic  acids  and  a  volatile  oil.  The  taste 
of  the  drug  is  bitter.  This  is  caused  by  amorphous  hop  resins  rather 
than  by  alkaloids.  Lupulin  to  be  of  value  must  be  derived  from  the 
best  Bohemian  hops.  It  must  also  be  fresh  and  have  undergone  no 
exposure  to  light  or  heat. 

The  active  principle  of  lupulin  is  closely  related  to  valerianic  acid. 
Taken  by  the  mouth  lupulin  causes  a  sense  of  warmth  first  in  epigas- 
trium and  later  over  whole  abdomen.  It  is  a  mild  diuretic  and  in  some 
persons  lowers  the  pulse  rate  from  ten  to  twenty  beats  a  minute.  The 
properties  of  the  drug  to  which  Doctor  Reilly  desires  particularly  to  call 
attention  are  its  hypnotic  and  anodyne  properties.  In  twenty-grain 
doses  repeated  in  a  half  hour  it  has  a  strong  tendency  to  produce  sleep 
and  also  to  relieve  nervousness,  particularly  that  following  excesses. 

As  a  pain-relieving  agent  it  is  to  be  classed  with  the  milder  anodynes. 
This  property  makes  it  of  value  in  the  colics  of  children,  in  acute  pros- 
tatic disease  and  in  neurasthenia  and  hysteria.  It  is  also  of  value  in 
headache,  especially  of  the  occipital  variety,  and  in  the  pains  of  menstru- 
ation when  not  caused  by  pathologic  lesions. 

In  its  administration  aromatic  spirits  of  ammonia  forms  a  good 
vehicle  for  a  liquid  preparation.  It  may  also  be  mixed  with  sugar  when 
it  is  given  to  children.  Generally,  however,  it  is  best  administered*  in 
capsules.  It  can  be  substituted  for  opium  in  treating  children  and  for 
the  coal-tar  products  in  many  instances.  Indeed,  its  property  of  meet- 
ing the  conditions  wherein  a  coal-tar  product  is  often  thought  to  be 
indicated  is  considered  by  Doctor  Reilly  to  constitute  its  chief  claim  to 
the  attention  of  the  profession.  This  view  is  shown  by  the  following 
quotation  taken  from  the  closing  portion  of  this  paper : 

"In  this  era  of  a  high-tension  civilization  the  practitioner  is  not 
infrequently  brought  face  to  face  with  the  treatment  of  pains  and  aches 
and  insomnias  which  are  not  in  themselves  severe  and  do  not  have  any 
organic  disease  as  a  cause.  These  patients  are  neurotic  and  high  strung 
and  are  not  suffering  enough  to  demand  the  use  of  an  opiate,  and  yet 
in  these  very  people  habits  are  easily  formed.  The  coal-tar  series  of 
the  past  decade  has  seemed  the  surest  way  out  of  such  a  dilemma.  The 
laity  know  it  as  well  as  we  do  and  act  accordingly.  Now  that  the 
formation  of  a  coal-tar  product  is  generally  recognized,  it  will  probably 
be  a  major  problem  in  the  next  generation.  Any  one  who  has  seen  the 
cyanosis,  palpitation,  et  cetera,  following  the  use  of  any  of  these  agents 
in  some  people  must  conclude  that  they  are  not  in  any  case  without 
some  harm,  however  slight  it  may  be.  In  many  of  the  cases  described 
above  in  which  we  are  tempted  to  use  the  coal-tar  series,  we  may  sub- 
stitute lupulin  and  we  may  go  home  and  sleep  soundly,  confident  that 
the  patient  will  have  been,  in  a  measure,  relieved  and  that  he  will  not 
be  found  dead  in  bed  the  next  morning  as  has  not  infrequenty  happened 
when  an  acetanilid  powder  has  been  taken  to  soothe  his  nervous 
complaints." 


CONGRESS  OF  PHYSICIANS.  231 

EDITORIAL  COMMENT. 


THE  PORTUGUESE  INTERNATIONAL  CONGRESS  OF 

PHYSICIANS. 

Lisbon  afforded  every  desideratum  to  render  the  recent  Fifteenth 
International  Medical  Congress  a  complete  scientific  and  numerical 
success  barring  the  Latin  tongue  and  a  lack  of  delegates.  The  former 
militated  against  a  cosmopolitan  participation  in  the  discussional  work 
of  the  sections,  while  the  latter  essential  was  not  in  evidence  to  marked 
degree,  registration  showing  the  presence  of  only  about  sixteen  hun- 
dred, fifty  of  whom  were  from  the  United  States.  The  idea  of  two 
successive  Latin  congresses  was  not  calculated  to  insure  international 
attendance,  and  a  practical  test  of  the  experiment  has  demonstrated 
that  the  delegates  hailed  principally  from  Portugal,  Spain,  and  other 
countries  in  which  the  vernacular  contemplates  Latin  derivation. 

*     *     * 

The  Congress  was  convened  by  King  Carlos  on  Thursday,  April 
19,  and  continued  its  sessions  through  the  week  ending  April  26,  the 
address  of  welcome,  an  interesting  discourse,  being  read  by  His 
Majesty  in  French.  The  speaker  was  supported  on  either  side  by 
Queen  Amelie  and  the  Queen  Dowager,  the  former,  by  the  way,  being 
a  regular  physician,  a  trained  nurse,  and  one  of  the  most  intellectual 
women  of  the  age.  The  general  addresses  reflected  the  present  status 
of  practical  medicine  and  surgery.  Aaser,  of  Christiania,  detailed  the 
"Relations  of  Acute  Infectious  Diseases  With  Tuberculosis";  Boyce, 
of  Liverpool,  discussed  "The  Prophylaxis  of  Yellow  Fever  as  the 
Result  of  the  1905  Epidemic  in  Central  America  and  New  Orleans; 
Brissaud,  of  Paris,  talked  on  "Infantilism";  Crocq,  of  Brussels, 
described  "The  Mechanism  of  Reflexes  and  of  Muscular  Tonus" ;  von 
Hansemann,  of  Berlin,  revealed  "The  Significance  of  Domestication 
for  Diseases  of  Animals  and  Man";  Neumann,  of  Vienna,  related 
"The  Anatomic  Causes  of  Syphilitic  Relapses  and  Methods  to  Follow 
to  Combat  Them" ;  Reclus,  of  Paris,  discoursed  on  "Local  Anesthet- 
ics" ;  de  TarchanoflF,  of  Saint  Petersburg,  recounted  the  possibilities  of 
"Radium  in  Biology  and  Medicine,  or  Organotherapy  of  Our  Days" ; 
while  our  own  Senn,  of  Chicago,  made  "A  Plea  for  the  International 
Study  of  Carcinoma."  The  programs  of  the  twenty  different  sections 
afforded  abundant  material  for  consideration,  in  fact  more  than  could 
be  properly  discussed  during  the  sessions  notwithstanding  many  of  the 
titles  listed  were  unsupported  by  paper  or  author.  The  total  number 
of  essays  and  addresses  announced  was  two  hundred  fifty,  representing 
one  hundred  forty  different  subjects,  but  comparatively  little  very  new 
was  added  to  our  store  of  knowledge.  The  operation  of  Gigli,  cutting 
the  iliac  bone,  was  offered  as  a  substitute  for  symphysiotomy.     Frank 


232  EDITORIAL  COMMENT. 

recommended  a  suprapubic,  extraperitoneal  Cesarean  operation,  claim- 
ing superiority  for  this  procedure,  especially  in  septic  cases.  The 
American  operation  for  fibroids  received  endorsement.  Discussion 
concerning  yellow  fever  elicited  expression  of  doubt  as  to  mosquitoes 
being  the  only  cause  of  the  scourge.  Tuberculosis  received  attention 
commensurate  with  the  importance  of  the  subject,  Bernheim  urging 
the  appointment  of  an  international  prophylactic  commission  to  draft 
a  code  of  regulations  bearing  on  the  disease. 

♦     ♦     ♦ 

The  social  features  of  the  event  were  numerous,  some  being 
decidedly  elaborate.  The  various  functions  included  receptions,  din- 
ners, garden  parties,  excursions,  bull  fights,  et  cetera.  The  dinner 
tendered  by  the  King  was  a  brilliant  affair.  It  was  attended  by  one 
hundred  fifty  official  delegates,  court  officials,  and  ambassadors,  who, 
together  with  the  King,  Queen,  Queen  Dowager,  diplomats,  and  mili- 
tary officers  increased  the  number  to  two  hundred.  The  American 
delegates  were  tendered  a  dinner  by  our  representative  at  the  Court  of 
Lisbon,  Charles  Page  Bryan,  covers  being  spread  for  fifty  guests. 
The  King  and  Queen  gave  a  garden  party  in  the  royal  grounds,  and 
the  Marquis  of  Montserrat  treated  the  guests  to  another  garden  party 
in  his  grounds  at  Cintra,  while  a  reception  was  tendered  by  the  city 
of  Lisbon  at  the  Hotel  de  Ville. 

The  next  meeting  will  be  held  at  Budapest  three  years  hence,  the 
Hungarian  invitation  having  been  backed  by  a  governmental  appro- 
priation of  fifty  thousand  dollars. 


ANNOTATIONS. 


THE  TREATMENT  OF  CANCER  WITH  TRYPSIN. 

Probably  no  disease  is  fraught  with  more  disastrous  consequence 
than  cancer.  Although  the  medical  treatment  of  the  malady  has  hith- 
erto been  of  a  somewhat  empirical  nature,  the  result  of  recent  experi- 
ment would  seem  to  indicate  that  the  etiology  and  therapy  of  the 
growth  will  soon  be  known  factors.  Speculation  bearing  on  the  cause 
has  given  rise  to  both  humorous  and  scientific  theories,  and  among 
the  latter  that  of  Beard,  of  Edinburgh  University,  seems  sufficiently 
meritorious  to  elicit  comment.  Beard  contends  that  migrating  cells 
exist  in  all  parts  of  the  organism  and  that  under  normal  conditions 
they  are  merged  with  the  fixed  cells  of  the  body.  However,  in  certain 
disease  conditions,  from  causes  at  present  undetermined,  the  wanderer 
fails  to  unite  with  a  fixed  cell,  thus  becoming  foreign  and  producing 
the  malignant  growth — cancer.  This  view  is  a  slight  modification  of 
Cohnheim's  theory,  but  Beard  has  augmented  the  hypothesis  by  ven- 
turing the  assertion  that  the  growth  may  be  directly  traceable  to  the 


RACE  SUICIDE.  233 

absence  of  some  systemic  product — a  substance  which  is  calculated  to 
destroy  the  malicious  nature  of  the  aberrant  cell  and  convert  it  into 
normal  tissue.  Beard  being  an  embryologist,  has  had  abundant  oppor- 
tunity to  study  various  forms  of  life  in  developmental  stages,  and  has 
observed  that  immediately  upon  the  establishment  of  the  pancreatic 
function  in  fishes  the  wandering  cell  disappears.  Using  this  phenome- 
non in  the  fish  as  a  possible  clue  upon  which  to  establish  a  logical  treat- 
ment, Beard  employed  trypsin  in  cancerous  mice  with  apparent  good 
result,  the  wandering  cell  disintegrating  and  leaving  the  normal  cell 
unimpaired.  The  product  has  been  used  to  some  extent  on  human 
l>eings  with  the  idea  of  preventing  recurrence  of  the  disease  after 
operation,  and  from  all  appearances  the  effect  has  been  gratifying. 


THE  DEMISE  OF  PROFESSOR  CURIE  IN   PARIS. 

Professor  Curie,  who  with  his  wife  shared  the  honor  of  giving  to 
science  a  new  chemical  element — radium,  died  on  April  19,  from 
injuries  sustained  in  a  collision  with  a  vehicle  in  the  streets  of  the 
French  metropolis.  Curie  married  a  Polish  woman/  a  profound  stu- 
dent of  science,  who  had  been  a  worker  in  his  research  laboratory,  and 
after  six  years  of  conjoint  and  untiring  labor  their  discovery  of  radium 
was  announced  in  1898.  The  nature  of  the  element  upset  some  of  the 
supposedly  fixed  chemical  hypotheses  such  as  the  atomic  theory  and  the 
theory  of  the  conservation  of  energy,  and  the  enthusiasm  of  certain 
therapeutists  for  a  time  gave  the  product  undue  prominence  in  the 
domain  of  medicine.  In  1903  Professor  Curie  received,  in  conjunc- 
tion with  his  wife,  the  Nobel  prize  for  scientific  research,  and  in  the 
same  year  Madam  Curie  was  awarded  the  Osiris  prize  of  $12,000. 
That  the  usefulness  of  radium  and  many  of  its  properties  had  not  been 
determined.  Curie  was  convinced,  and  he  was  deeply  absorbed  in 
research  at  the  time  of  his  premature  demise.  In  his  death  the  world 
lias  lost  a  man  of  vast  scientific  attainment  and  one  who  was  calculated 
to  revolutionize  certain  fields  of  science.  A  widow  and  child  eight 
years  old  are  immediate  mourners. 


DOCTOR  REED  ON  RACE  SUICIDE. 

Contrary  to  the  views  of  President  Roosevelt  on  the  race  suicide 
'  -question,  are  those  of  Doctor  Charles  A.  L.  Reed,  of  Cincinnati,  who 
argues  that  few  children  properly  reared  will  better  subserve  the 
common  weal  than  many  children  developed  in  unsuitable  environ- 
ment, the  idea  being  that  conditions  of  creature  are  paramount  to 
commands  of  creator.  In  the  course  of  a  lecture  on  the  "American 
Family"  the  doctor  said:  "We  see  in  a  declining  birth-rate  only  a 
natural  and  evolutional  adjustment  of  race  to  environment — an 
adjustment  that  insures  rather  than  menaces  the  perpetuation  of  our 
kind  under  favoring  conditions."     Race  suicide  consequently  implies. 


234  EDITORIAL  COMMENT. 

according  to  the  speaker,  not  aversion  to  conception,  but  an  unselfish 
regard  for  the  proper  development  of  the  offspring.  Continuing, 
Doctor  Reed  said:  "American  women  recognize,  subconsciously,  pos- 
sibly, certainly  not  in  definite  terms,  but  they  nevertheless  recognize, 
the  force  of  the  law  enunciated  by  Mr.  Spencer  that  whatever  conduces 
to  the  highest  welfare  of  offspring  must  more  and  more  establish  itself, 
since  children  of  inferior  parents  reared  in  inferior  ways  will  ever  be 
replaced  by  children  of  better  parents  reared  in  better  ways." 


CONTEMPORARY. 


•PHYSICIANS  AND  PHILOSOPHERS. 

[PKOFBSSOR  CHARLBS  WILLIAM  SUPBK,  OP  OHIO  UNIVBRSITY,  IN  POPULAR  SCIKNCB  MONTHLY.] 

{CoHiiHU*d  from  page  qi.) 

It  will  scarcely  be  denied  by  those  best  qualified  to  judge  that  of 
the  three  learned  professions  that  of  medicine  is  still  the  best  fitted 
to  stimulate  thought  and  investigation.  It  is  less  hemmed  in  by 
tradition,  and  is  of  immediate  public  interest.  The  man  who  conquers 
a  dangerous  disease  or  who  performs  a  difficult  surgical  operation 
needs  no  other  endorsement.  Unless  he  allows  avarice  to  draw  him 
into  a  practice  more  extensive  than  his  constitution  will  bear,  he  will 
have  a  fair  degree  of  leisure  for  liberalizing  his  mind  by  the  study  of 
subjects  outside  of  his  particular  sphere.  The  history  of  modem 
times  no  less  than  that  of  antiquity  offers  many  examples  of  medical 
men  whose  interests  were  almost  coextensive  with  those  of  mankind. 
That  the  physician,  the  investigator,  the  philosopher  and  the  litterateur 
may  be  happily  blended  in  one  person  is  finely  illustrated  by  the  latest, 
though  it  is  to  be  hoped  not  the  last,  volume  either  of  the  man  or  of 
his  kind,  the  *Aequanimitas'  of  Doctor  Osier. 

No  one  who  is  acquainted  with  human  nature  will  be  surprised 
when  he  learns  that  the  class  of  medical  practitioners  known  as 
'quacks'  flourished  among  the  comparatively  enlightened  Greeks  of 
ancient  times.  Often,  however,  the  quack  is  one  who  strives  after 
results  by  a  method  that  has  been  tabooed  by  the  corporation  to  whose 
regulations  it  is  assumed  that  he  ought  to  have  subscribed.  Though 
he  is  an  outlaw,  before  the  tribunal  of  mortals  he  may  be  just  as  good 
as  if  he  were  an  in-law.  That  mysterious  and  apparently  inscrutable 
part  of  our  being  known  as  the  nervous  system  has  always  presented 
problems  which  medical  practitioners  have  been  unable  to  solve.  Why 
should  not  a  faith-cure  be  as  legitimate  as  any  other  cure,  provided  it  is 
genuine?  And  there  have  been  faith-cures  time  out  of  mind.  When 
persons  cannot  control  their  own  imaginations,  the  task  would  seem  to 
be  doubly  difficult  for  any  one  else.  Often  the  most  important  part 
of  the  physician's  business  is  to  arouse  in  his  patient  the  will  to  get 
well,  and  whatever  will  accomplish  this  cannot  be  stigmatized  as  fraud. 


PHYSICIANS  AND   PHILOSOPHERS.  235 

When  hope  is  lost  all  is  lost.  I  have  known  not  a  few  persons  who 
died  because  they  did  not  want  to  live  or  were  at  least  indifferent ;  and 
probably  an  equal  number  who  materially  lengthened  their  lives  by 
the  mere  determination  not  to  die.  My  attention  was  drawn  to  this 
phase  of  pathoIog>'  many  years  ago  by  a  curious  incident  that  came 
under  my  observation  when  I  was  a  mere  lad.  I  did  not  hit  upon  the 
explanation  until  long  afterwards.  I  have  seen  the  same  thing 
repeated  many  times  since  then.  A  vender  of  medicaments  of  his  own 
concoction  used  to  visit  our  neighborhood  about  twice  a  year.  One 
day  as  he  was  driving  along  he  began  to  feel  unwell,  and,  contrary  to 
the  proverb  that  doctors  never  take  their  own  medicines,  picked  from 
fiis  chest  a  vial  containing  what  he  believed  would  afford  him  relief, 
and  drank  some  of  its  contents  without  looking  at  the  label.  Having 
occasion  shortly  afterward  to  leave  his  wagon  to  visit  one  of  his  cus- 
tomers, it  occurred  to  him  that  he  had  drunk  from  a  bottle  containing 
a  strong  poison.  He  at  once  began  to  feel  very  sick.  A  sort  of  stupor 
seized  him  and  he  became  so  weak  that  he  could  hardly  walk.  As 
soon  as  he  could  get  back  to  his  medicine-chest  he  looked  at  his  bottles 
again,  when,  to  his  great  joy  and  greater  relief,  he  found  that  he  had 
taken  just  what  he  intended.  The  man  declared  afterwards  that  he 
believed  he  would  have  died  if  he  had  not  had  the  means  of  ascertain- 
ing the  facts  in  the  case. 

Though  the  ancients  knew  little  of  the  structure  of  the  nerves,  they 
were  well  aware  of  the  influence  of  the  imagination  as  a  therapeutic 
agency.  The  walls  of  many  of  their  temples  were  covered  with  tablets 
and  votive  offerings  in  testimony  of  gratitude  to  the  god  by  whom  the 
sick  were  healed.  Faith-cures  and  christian  science  are  therefore  by 
no  means  a  new  thing  under  the  sun,  but  something  very  old  under 
new  names.  Though  the  ancients  rarely,  or  not  at  all,  dissected 
human  bodies,  they  had  a  fairly  definite  knowledge  of  anatomy  derived 
from  the  inspection  of  brutes.  The  bony  structure  could  be  readily 
studied  with  the  aid  of  the  skeletons  that  were  plentiful  enough  in 
countries  dotted  with  battlefields.  The  Persian  invasion  alone  proba- 
bly left  tens  of  thousands  of  corpses  strewn  along  the  retreat  of  the 
great  king.  The  aversion  to  the  dissection  of  cadavers  that  was  felt  by 
many  of  the  Greeks  seems  to  have  been  connected  with  their  reverence 
for  the  human  form.  It  was  regarded  as  a  sacrilege  to  mutilate  even  a 
corpse.  The  treatment  which  the  dead  body  of  Leonidas  received  at 
the  hands  of  Xerxes  was  due,  as  Herodotus  expressly  informs  us,  to 
the  extraordinary  exasperation  he  felt  against  the  Spartan  king  for  his 
fierce  resistance  to  the  Persian  advance.  Though  Achilles  had  dragged 
the  dead  body  of  Hector  many  times  around  the  walls  of  Troy,  yet 
Apollo  preserved  it  uninjured.  This  reverence  for  the  *human  form 
divine,'  like  many  others  superstitions,  interfered  seriously  with  the 
progress  of  science.  The  favorite  gods,  Zeus  and  Apollo,  were  repre- 
sented as  physically  perfect  men.  The  effects  of  this  sentiment  are 
especially  evident  in  the  manner  by  which  those  condemned  to  death 
were  executed.    There  seems  to  be  no  other  explanation  of  the  singular 


236  MEDICAL  NEWS. 

custom  of  administering  the  hemlock  juice  than  the  desire  to  leave  the 
body  after  death  as  nearly  as  possible  as  it  appeared  in  its  living  state. 
That  the  rule  was  departed  from  under  special  circumstances  and  in 
times  of  great  excitement  is  no  valid  argument  against  the  correctness 
of  the  explanation. 

[TO  Bl  CONTINUBD.] 


MEDICAL  NEWS. 


A  GRIST  OF  MEDICAL  GRADUATES. 

The  thirty-eighth  annual  commencement  exercises  of  the  Detroit 
College  of  Medicine  were  held  in  Light  Guard  Armory,  Thursday  even- 
ing, May  17,  1906,  when  eighty-two  candidates  received  the  degree  of 
Doctor  of  Medicine.  The  address  of  the  occasion,  which  will  be  pub- 
lished in  the  next  issue  of  this  journal,  was  delivered  by  Doctor  Frank 
B.  Walker.  After  the  award  of  diplomas  a  banquet  was  tendered  the 
graduating  class  at  Hotel  Cadillac  by  the  Faculty  of  the  College.  Fol- 
lowing is  a  list  of  those  upon  whom  degrees  were  conferred :  S.  M. 
Angle,  O.  Amdt,  A.  W.  Blain,  Jr.,  G.  K.  Boyajian,  G.  T.  Britton,  C.  W. 
Burge,  J.  F.  Burleson,  R.  C.  Burt,  J.  B.  Chapman,  R.  L.  Clark,  C.  W. 
Courville,  F.  L.  Covert,  R.  E.  Dawson,  W.  A.  DeFoe,  P.  J.  De  Free,  W. 
H.  Dunham,  G.  A.  Easton,  O.  A.  Fischer,  E.  F.  Fisher,  F.  G.  Fisher,  H. 
I.  Flanders,  R.  R.  Fox,  H.  E.  Eraser,  F.  D.  German,  G.  C.  Griffis,  J.  L. 
Hammond,  T.  P.  Hanna,  J.  H.  Hanson,  H.  Harrison,  L.  L.  Harrison, 
W.  H.  Haughey,  Jr.,  L.  E.  Hemenway,  J.  H.  Henry,  C.  F.  Hinchman, 
W.  Hipp,  M.  C.  Hubbard,  E.  R.  Johnston,  W.  G.  Kanter,  J.  C.  Ken- 
ning, H.  I.  Kedney,  J.  E.  King,  J.  A.  Klahs,  B.  G.  W.  Larke,  R.  W. 
Luce,  J.  F.  McKay,  J.  C.  MacKenzie,  J.  R.  MacKenzie,  C.  L.  D.  Mc- 
Laughlin, A.  R.  Miller,  F.  B.  Miner,  L.  Mueller,  F,  E.  Murphy,  C.  H. 
Oakman,  H.  A.  Osborn,  H.  A.  Ott,  W.  C.  Pepin,  H.  Pepper,  M.  E. 
Pickens,  A.  C.  Potter,  A.  D.  Potter,  F.  A.  Pratt,  S.  W.  Randoph,  C.  J. 
Rolhnan,  D.  U.  Saunders,  F.  M.  Singer,  C.  A.  Smith,  W.  H.  Snyder, 
R.  E.  Spinks,  U.  G.  Spohn,  C  M.  Stafford,  T.  C.  Starrs,  F.  E.  Stevens, 
H.  A.  Stewart,  C.  H.  Stiles,  J.  E.  Strain,  F.  M.  Summerville,  R.  S. 
Taylor,  F.  Tremblay,  E.  C.  Van  Sickle,  J.  R.  Van  Sickle,  W,  J.  Voor- 
heis,  F.  T.  Zieske. 


MINOR  INTELLIGENCE. 


The  alarming  increase  of  pneumonia  in  Indiana,  and  the  large 
number  of  deaths  incident  to  the  disease,  has  instigated  the  issuance  of 
a  bulletin  by  the  State  Board  of  Health  calling  the  attention  of  physi- 
cians to  the  prevalence  of  the  affection,  and  admonishing  them  to 
instruct  the  laity  as  to  its  seriousness  and  the  best  means  of  combatting 
the  dissemination  of  the  pneumococcus. 


MINOR  INTELLIGENCE.  237 

Doctor  Emma  Cook,  a  prominent  women  practitioner  of  Detroit, 
died  of  anemia  on  April  14,  aged  fifty-eight  years.  Doctor  Cook  was 
a  graduate  of  the  University  of  Michigan,  with  the  class  of  1892. 

A  MEMORIAL  service  was  held  in  Berlin  on  April  i,  to  commem- 
orate the  death  of  Doctor  Max  Nitze,  the  inventor  of  the  cystoscopy 
An  exposition  has  also  been  conducted  showing  the  various  stages  of 
development  in  the  instrument,  and  the  material  originally  employed 
by  Nitze. 

The  American  Gastroenterologic  Association  will  meet  in  Boston, 
June  4  and  5,  1906.  The  president's  address  will  be  delivered  by 
Doctor  Henry  W.  Bettmann,  of  Cincinnati,  on  "The  Mutual  Obliga- 
tions of  the  Surgeons  and  Internists  in  the  Proper  Development  of 
Gastric  Surgery." 

The  Ohio  State  Medical  Society  met  at  Canton  on  May  9,  for  a 
three  days'  session.  An  interesting  and  instructive  program  was  pre- 
sented. The  oration  in  Medicine  was  delivered  by  Doctor  John  C. 
Hemmeter,  of  Baltimore;  and  that  on  Surgery  by  Doctor  Harvey  C. 
Gaylord,  of  Buffalo. 

Verily,  this  is  an  age  of  remarkable  progress  in  medical  thought 
and  practice.  A  contemporary  reports  the  case  of  a  sightless  Wash- 
ingtonian,  to  whom  were  transplanted  the  eyes  of  a  Belgian  hare.  The 
operation  is  said  to  have  been  so  skilfully  performed  that  vision  was 
completely  restored! 

Professor  van  Ermenghem^  of  Brussels,  recently  announced 
before  the  Academy  of  Medicine  that  he  had  proven  almost  conclu- 
sively the  bacterial  origin  of  cancer,  and  further  stated  that  the  results 
obtained  in  a  long  series  of  experiments  have  led  him  to  the  belief  that 
serum  derived  from  the  organism  will  cure  the  disease. 

Doctor  Edward  Anthony  Spitzka,  formerly  connected  with  the 
Philadelphia  College  of  Physicians  and  Surgeons  as  demonstrator  of 
anatomy,  has  been  elected  to  the  professorship  of  general  anatomy 
in  the  Jefferson  Medical  College.  Doctor  George  McClellan  will 
occupy  the  chair  of  applied  anatomy  at  the  same  institution. 

The  Christian  Hospital,  of  Chicago,  an  institution  of  undetermined 
reputation,  was  recently  fined  $250  for  publishing,  without  sanction, 
the  name  of  Doctor  John  B.  Murphy  as  president  of  its  executive  board. 
The  hospital  authorities  persisted  in  their  employment  of  the  name, 
regardless  of  the  fact  that  Doctor  Murphy  secured  an  injunction 
restraining  them  from  so  doing,  hence  the  penalty. 

Over  a  million  circulars  of  warning  have  been  distributed  during 
the  past  two  years  by  the  German  Society  for  the  Prevention  of  Vene- 
real Disease.  The  campaign  has  been  very  thorough,  physicians,  dis- 
pensaries, and  the  army  being  the  agencies  through  which  the  dis- 
tributions were  effected.  It  is  the  purpose  of  the  society  to  issue  a 
similar  circular  to  women  and  young  girls  during  the  coming  year. 


238  MEDICAL  NEWS. 

Smallpox  has  wreaked  havoc  in  Chile  during  the  past  year,  the 
country  having  been  literally  infested  with  the  pest.  Since  January, 
1905,  more  than  eleven  thousand  cases  and  five  thousand  deaths  have 
been  recorded — a  powerful  argument  against  the  existing  sanitary 
regime  of  the  South  American  republic. 

Andrew  Carnegie  has  deviated  from  the  path  of  library  endow- 
ment by  promising  the  sum  of  $10,000  to  the  College  of  Physicians 
and  Surgeons,  of  Atlanta,  Georgia.  The  college  trustees  are  desirous 
of  raising  $100,000  for  the  purpose  of  erecting  new  buildings,  and  the 
steel  magnate's  gift  will  be  the  last  $10,000  of  this  amount. 

New  York  is  suffering  from  an  epidemic  of  diphtheria,  and  new 
cases  are  daily  recorded.  The  percentage  of  deaths  from  the  disease 
has  become  so  high  that  Health  Commissioner  Darlington  has  issued 
an  appeal  to  both  laity  and  profession  for  a  more  generous  employment 
of  antitoxin.     At  present  the  death  rate  is  fourteen  per  cent. 

The  commission  in  charge  of  the  Michigan  Sanatorium  for  Con- 
sumption has  chosen  a  site  two  and  one-half  miles  from  the  city  of 
Howell.  The  location  is  an  ideal  one,  since  it  possesses  excellent  nat- 
ural advantages,  being  at  an  elevation  of  one  thousand  one  hundred 
feet  above  sea  level,  and  having  running  water,  timber  and  a  lake. 
The  property,  one  hundred  ninety  acres,  was  presented  by  the  city  of 
Howell. 

A  committee  composed  of  American  and  European  physicians  has 
been  formed  to  solicit  and  receive  subscriptions  for  the  erection  of  a . 
monument  to  the  late  Surgeon  Miculicz-Radecki,  of  Breslau.  W.  W. 
Keen,  of  Philadelphia;  W.  S.  Halsted,  of  Baltimore;  J.  B.  Murphy,  of 
Chicago;  and  F.  Kammerer,  of  New  York,  comprise  the  quartet  of 
Americans  who  will  represent  the  work  in  the  United  States  and 
Canada. 

The  establishment  of  a  new  filtration  plant  in  connection  with  the 
Jerome  Park  reservoir,  New  York,  is  being  agitated,  the  city  com- 
missioner having  submitted  preliminary  plans  to  Mayor  McClellan. 
The  present  move  was  instituted  to  offset  the  plans  of  a  rival  faction, 
whose  idea  contemplated  the  purchase  of  a  new  site,  which,  together 
with  the  cost  of  building  the  filter,  would  indebt  the  city  to  the  extent 
of  $8,500,000,  according  to  a  very  low  estimate.  The  plan  of  the 
present  projectors  is  to  utilize  the  park  property  for  the  enterprise. 

The  consolidation  of  the  Medical  College  of  Indiana,  the  Central 
College  of  Physicians  and  Surgeons,  and  the  Fort  Wayne  School  of 
Medicine  has  been  effected,  and  the  trio  will  henceforth  form  a  com- 
ponent part  of  the  Purdue  University  at  Indianapolis.  In  a  circular 
announcing  the  change,  the  executives  of  the  several  colleges  explain 
the  reason  therefor  by  stating  that  a  concentration  of  interests  in  a  city 
of  sufficient  size  to  offer  ideal  clinical  facilities  will  best  conserve  the 
interests  of  all  concerned — students  and  teachers  alike.  The  consolida- 
tion was  effected  after  an  agfitation  covering  a  long  period  of  years. 


DIFFERENTIAL  DIAGNOSIS.  239 

A  WOOD  alcohol  debauch  is  responsible  for  one  death  and  the  serious 
illness  of  several  prisoners  confined  in  the  military  prison  at  Governor's 
Island.  The  product  was  undoubtedly  secretly  conveyed  to  the  in- 
mates by  visitors.  The  deleterious  results  ensuing  from  the  employ- 
ment of  wood  alcohol,  even  in  commercial  pursuits,  has  led  to  the  intro- 
duction of  several  bills  before  the  House  Committee  on  Ways  and 
Means  at  Washington,  for  the  removal  of  the  internal  revenue  tax  on 
grain  alcohol  for  industrial  purposes.  Painters  and  varnishers  are 
especially  subject  to  the  vapors  of  the  wood  product,  and  a  chair 
finisher  who  lost  his  eyesight  from  this  cause  appeared  before  the  com- 
mittee to  support  the  measure. 


RECENT  LITERATURE. 


REVIEWS. 


DIFFERENTIAL  DIAGNOSIS  AND  TREATMENT  OF 

DISEASE.* 

If  the  title  of  this  book  is  comprehensive,  the  contents  are  no  less 
so.  This  includes :  "The  Technique  of  Diagnosis  and  Laboratory  Aids 
to  Clinical  Diagnosis,"  55  pages;  "General  Therapeutic  Management," 
pages  55-87;  "Pediatrics,"  87-229;  "The  Digestive  System,"  229-332; 
"Circulatory  System,"  33-409;  "Respiratory  System,"  409-469;  "Gen- 
ito-Urinary  System,"  469-533;  Osseous,  Muscular  and  Articular 
System,"  533-602;  "Infectious  and  Contagious  Diseases,"  602,  643; 
"Diseases  Due  to  Faulty  Metabolism,  Faulty  Internal  Secretions  and 
Derangement  of  Ductless  Glands,"  643-675;  "Nervous  System,"  675- 
769;  "Dermatologic  Memoranda,"  769-806;  "Otic  Memoranda,"  806- 
812;  "Ophthalmic  Memoranda,"  812-823;  "Anesthesia,  Intoxications, 
Miscellaneous  Ailments,  Keeping  Case  Records  and  Accounts,"  823- 
838.  This  classification  seems  somewhat  arbitrary,  but  may  have  some 
practical  advantages  that  have  not  made  themselves  apparent  to  the 
reviewer.  Similar  reasons,  probably,  have  placed  "dysentery"  in  the 
chapters  on  "Pediatrics  and  Digestive  System,"  lobar  pneumonia  and 
tuberculous  pneumonia"  in  the  "Respiratory  System,"  et  cetera.  A 
more  orderly  though  less  "practical"  classification,  with  a  good  index, 
would  have  answered  the  practical  need  just  as  much,  and  would  almost 
certainly  have  saved  space. 

As  for  the  text  itself,  the  author  has  acquitted  himself  well  of  a 
task  that  at  first  sight  seems  almost  impossible.  That  is,  he  has  given 
some  directions  regarding  each  of  the  numerous  topics  included   in 


240  RECENT  LITERATURE. 

his  scheme.  Necessarily  these  are  brief,  in  many  cases  so  brief  as  to 
make  the  work  more  useful  for  hurried  reference  in  an  unexpected 
time  of  need,  rather  than  for  thorough  information,  such  as  the  prac- 
titioner, or  even  the  advanced  student,  should  have.  The  views  of  the 
author  are  on  the  whole  sound,  often  admirable.  The  introduction 
should  be  read  by  all  who  are  preparing  for  the  medical  course.  Other 
indications  of  the  high  principals  held  by  the  author  are  often  encoun- 
tered through  the  text,  and  do  not  seem  to  suffer  from  occasional  jux- 
taposition with  recommendations  of  remedies  not  yet  admitted  to  the 
"United  States  Pharmacopeia."  In  general,  too,  the  directions  for 
diagnosis  and  treatment  are  sound,  though  lapses  are  not  infrequent. 
The  author's  tendency  to  look  for  and  treat  a  malarial  complication 
takes  one  back  to  the  preplasmodial  days.  His  opinion  of  the  value 
of  waxy  casts — to  indicate  chronic  rather  than  acute  processes — is  cer- 
tainly wrong.  In  some  of  the  technical  directions  haste  has  led  to 
omissions,  sometimes  important  for  beginners,  as  in  the  descriptions 
of  blood  stains,  page  44,  the  preparation  of  aniline  water,  and  others. 
Sometimes  the  omissions  are  tantalizing,  as  when  we  are  told  (page  52)  : 
"There  are  peculiar  cell  reactions  so  that  we  can  determine  which  cells 
come  from  primary  and  which  from  secondary  tumors,"  without  further 
descriptions  of  the  alleged  reactions.  Repetitions  are  notably  frequent. 
Antique  beliefs  are  sometimes  resuscitated,  as  in  the  assertion  of  the 
diagnostic  importance  of  Sanirelli's  bacillus.  lodophilia  seems  unduly 
exalted  and  its  history  set  forth  with  details  that  would  gain  by  refer- 
ences to  original  articles. 

The  directions  for  treatment  are  in  the  main  good,  but  usually  are 
too  brief  for  anything  but  momentary  use.  Typhoid  fever  has  a  little 
over  two  pages ;  pneumonia  not  much  more  than  one  page  on  treatment. 

The  work  is  profusely  illustrated,  but  many  of  the  pictures  belong 
to  the  realm  of  portraiture  rather  than  medicine.  If  one  must  have  a 
cut  of  a  stomach  tube  it  would  seem  better  to  picture  that  sort  in  general 
use.  The  cut  labelled  "bronchocele,"  and  also  the  description,  seem  to 
limit  the  use  of  that  term  to  bronchial  cyst,  which  is  certainly  not  cus- 
tomary. The  position  of  the  patient  blowing  bottles  is  not  one  that  is 
likely  to  further  the  result  desired. 

On  the  whole,  while  the  plan  and  scope  of  the  book  are  good,  it 
requires  considerable  alteration  before  it  can  be  recommended  for 
undergraduates.  For  the  practitioner  who  knows  enough  to  avoid  the 
mistakes,  it  will  be  interesting;  to  others  it  might  be  dangerous  if  fol- 
lowed blindly.  It  is  to  be  hoped  the  necessary  corrections  may  soon 
be  made,  so  that  the  work  will  all  be  as  good  as  its  best  parts. 

G.  D. 

*A  Text-Book  for  Practitioners  and  Advanced  Students.  By 
Augustus  Caille,  M.  D.  With  two  hundred  and  twenty-eight  Illus- 
trations in  the  text.  New  York  and  London :  D.  Appleton  &  Company, 
1906. 


%  itesician  aulr  Swrgeon 

A  PROFESSIONAL  MEDICAL  JOURNAL. 


VOLUME  XXVIII.  JUNE,  1906.  NUMBER  VI. 


ORIGINAL  ARTICLES. 


ADDRESSES. 


PRACTICAL  DISCOURSE  TO  EMBARKING  PHYSICIANS.* 
By  frank  B.  walker,  Ph.  B.,  M.  D.,  Detroit. 

AOJimCT  ntOFBS60R  OF  ftUKGUlY  IN  THB  DBTKOIT  COLLBGB  OF  MBDICINB. 

Mr.  President,  Associates  on  the  Faculty,  Members  of  the  Graduating 
Clctss,  Ladies  and  Gentlemen: 

It  is  now  thirty-eight  years  since  this  college  first  opened  its  doors 
to  aspiring  students  of  medicine.  It  is  not  long  in  point  of  time,  but 
from  the  viewpoints  of  work  done  and  of  medical  progress,  the  vista 
is  broad  and  inspiring.  Classes  have  come,  pursued  the  round  of  col- 
lege life,  and  gone,  until  already  more  than  seventeen  hundred  and  fifty 
students  have  passed  before  the  eyes  of  a  critical  faculty  and  taken  up 
the  practice  of  medicine  and  surgery  in  thirty-nine  of  the  United  States 
and  in  many  places  abroad.  Think  of  the  hours  of  study  and  the  efforts 
to  teach  which  this  army  of  trained  men  represent;  calculate  in  your 
mind  the  services  of  each  alumnus  and  the  sum  total  of  them  all  in  the 
interest  of  life  and  health ;  picture  if  you  can  the  want  of  all  this  pro- 
fessional skill,  the  kindly  offices  of  all  these  devotees  to  duty,  and  then 
will  you  not  place  a  high  and  lasting  regard  upon  the  results  achieved 
through  the  instrumentality  of  this  institution  ? 

Thirty-eight  years  ago  medical  education,  in  spite  of  a  hoary  past, 

was  in  a  very  rudimentary  stage  of  development.    No  one  of  us  may 

hope  to  see  the  science  perfected,  and  yet  those  who  have  lived  the  last 

two  scores  of  years,  have  witnessed  greater  advancement  in  the  science 

and  art  of  medicine  than  all  the  Methuselahs  of  the  past  combined. 

It  is  not  my  purpose  to  laud  this  faculty  or  to  proclaim  its  policy,  but 

results  have  demonstrated  the  effect  of  honest  and  earnest  endeavor 

^Address  before  the  graduating  class  of  the  Detroit  College  of  Medicine, 
Thursday  evening,  May  17,  1906. 


242  ORIGINAL  ARTICLES. 

ev^n  when  unaided.  Year  by  year  saw  added  responsibilities  put  upon 
the  college  if  she  would  do  her  full  duty  to  those  confiding  in  her  nur- 
ture, and  maintain  a  high  standing  among  her  sister  institutions.  These 
she  promptly  and  cheerfully  assumed  by  from  time  to  time  lengthening 
the  course  of  study  and  enlarging  its  scope,  by  erecting  larger  build- 
ings, installing  and  thoroughly  equipping  new  laboratories,  and  withal 
voluntarily  raising  the  standard  of  admission  even  though  it  materially 
cut  down  the  income.  All  this  has  been  accomplished  without  state, 
denominational,  or  other  outside  help,  without  any  adequate  financial 
remuneration  or  return  for  the  energy  expended,  and  often  at  a  pecuni- 
ary loss  to  those  engaged  in  the  work.  You  may  ask  then  the  reason 
or  need  for  all  this  labor  and  sacrifice.  For  answer  I  would  again 
point  to  the  results  obtained,  the  charity  bestowed,  for  in  truth  it  is  the 
benevolence  of  the  work  that  made  it  live  and  prosper. 

We  have  gathered  here  tonight,  in  keeping  with  a  custom  of  our 
own,  for  the  twofold  purpose  of  recognizing  publicly  and  authorita- 
tively the  completion  of  required  medical  study,  and  of  speaking  and 
responding  for  the  last  time  as  faculty  and  students.  You,  members 
of  the  graduating  class,  have  for  the  past  four  years  cast  your  lot  with 
us.  Whether  or  no  you  thoughtlessly  at  first  chose  your  Alma  Mater 
we  do  not  know ;  but  you  knew  at  least  that  this  college  was  particular 
as  to  who  and  what  you  were.  Now  that  you  have  remained  with  us 
through  to  the  end,  and  inasmuch  as  you  are  the  sons  not  of  Michigan 
alone  but  of  at  least  eight  different  states,  we  take  it  that  your  residence 
here  has  been  worth  while. 

As  the  mother-bird  makes  a  nest  wherein  to  rear  her  young,  and  as 
she  nurtures  and  protects  them  through  the  days  of  growth,  then,  when 
they  shall  have  attained  due  strength,  pushes  them  from  the  nest  to 
try  their  wings  in  flight,  now  guiding  and  now  supporting  them,  so 
your  Alma  Mater,  after  thorough  education  and  trial  of  your  strength, 
proud  of  your  attainments,  opens  again  her  doors  and  leads  you  forth 
to  do  your  part  in  the  world's  work.  Life  is  longer  than  a  generation ; 
duty  is  for  everyone ;  you  have  been  drafted  today. 

Before  dissolving  the  relations  of  the  past  four  }-ears  it  becomes 
us,  who  have  been  in  the  larger  school  of  experience,  to  give  you  form- 
ally a  few  words  of  counsel  on  matters  not  included  in  the  schedule  of 
instruction.  In  the  first  place  let  me  warn  you  not  to  be  deceived  by 
present  appearances.  As  at  your  christening  and  on  your  wedding  day, 
so  now  you  are  the  cynosure  of  all  eyes.  You  have  just  completed  a 
long,  difficult,  and  meritorious  course  of  study  and  are  about  to  be 
crowned  with  the  laurel  wreath  of  victory.  But,  unlike  the  victor  in 
the  games  of  Apollo,  your  real  work  is  not  done.  You  are  merely 
prepared  to  take  it  up.  In  the  school  of  instruction  you  have  been  fos- 
tered, excused,  and  protected.  In  the  school  of  experience,  of  which 
Father  Time  is  president,  you  will  have  to  be  solicitous,  self-reliant, 
and  courageous.    Work  is  the  law  of  our  being.    That  law  has  greater 


DISCOURSE  TO  EMBARKING  PHYSICIANS.  243 

significance  for  you  today  than  ever  before.  With  your  increased 
abilities  and  higher  aspirations  difficulties  will  be  greater  rather  than 
less.  You  will  have  opportunities  galore  but  you  will  also  find  as  many 
others  beside  you  seeking  to  take  advantage  of  them.  The  question  for 
you  then  is  how  to  succeed.  It  is  not  expected  of  me  as  the  spokesman 
of  the  faculty,  nor  is  it  fitting  on  this  occasion  to  descant  on  character 
as  a  text,  but  you  should  ever  bear  in  mind  that  high  ideals  are  essential 
to  great  success.  If  you  were  to  ask  me  to  state  in  a  word  how  to  attain 
success  I  would  answer,  deserve  it. 

The  first  practical  question  that  will  come  up  in  your  minds  will  be 
where  to  locate?  I  know  very  well  that  advice  on  this  point  is  seldom 
heeded.  Everyone  likes  to  find  his  own  niche  if  possible  and  is  willing 
to  follow  advice  only  in  case  it  coincides  with  his  own  wishes.  One 
injunction  above  all  others  on  this  subject,  however,  you  should  be 
given.  Do  not  buy  out  another  doctor's  practice.  There  may  be  good 
reasons  for  selling  and  the  location  may  be  desirable,  but  the  holding 
of  the  good  will  and  support  of  another  doctor's  patients  is  very  differ- 
ent from  purchasing  the  good  will  of  the  doctor  himself.  Only  recently 
a  letter  was  received  from  a  physician  in  the  State  of  Washington,  who 
asked  only  fifteen  thousand  dollars  for  his  practice  in  a  town  of  two 
thousand. 

Another  matter  upon  which  it  is  customary  to  give  advice  to  young 
physicians  is  that  of  marriage.  Seven  years  ago  we  heard  a  member  of 
this  faculty — strange  to  say,  still  a  bachelor — ^in  speaking  from  this 
platform,  declare  that  he  doubted  the  patriotism  of  a  man  who  does  not 
marry.  I  have  seen  many  classes  go  out  from  this  institution  but  I 
have  never  seen  one  whole  class  depart  in  single  blessedness.  This 
class  has  not  been  rigidly  polled,  but  I  have  been  told  that  there  are  at 
least  sixteen  benedicts  in  it  already,  and  another  can  scarcely  wait  until 
tomorrow  to  sing  like  a  lark  the  bliss  of  married  life.  From  my  own 
observation  I  believe  that  most  men  need  no  encouragement  to  marry. 
They  might,  however,  well  take  advice  in  regard  to  the  choice  of  a 
wife.  Burns  is  credited  with  having  divided  the  qualities  of  a  good 
wife  into  ten  parts.  Four  of  these  he  gave  to  good  temper,  two  to  good 
sense,  one  to  wit,  one  to  beauty — such  as  a  sweet  face,  eloquent  eyes, 
a  fine  person,  a  graceful  carriage ;  and  the  other  two  parts  he  divided 
among  the  other  qualities  belonging  to  or  attending  on  a  wife — such  as 
fortune,  connections,  education  (that  is  of  a  higher  standard  than  ordi- 
nary), family  blood,  et  cetera;  but  he  said :  "Divide  those  two  degrees 
as  you  please,  only  remember  that  all  these  minor  proportions  must  be 
expressed  by  fractions,  for  there  is  not  any  one  of  them  that  is  entitled 
to  the  dignity  of  an  integer." 

When  you  shall  have  located  you  will  do  well  to  ally  yourselves 
with  the  local  fraternity  by  joining  the  county  and  state  medical  soci- 
eties and  attending  their  meetings.  By  so  doing  you  will  acquire  some 
of  your  best  friends,  aid  your  establishment  in  the  community,  and 


244  ORIGINAL  ARTICLES. 

obtain  the  benefit  of  postgraduate  study  at  home.  It  goes  without  say- 
ing that  an  active  participation  in  the  affairs  of  these  organizations  will 
secure  the  best  results. 

Your  relations  with  your  fellow-practitioners  should  be  ef  the  most 
cordial  character.  For  your  own  sake  do  not  be  a  "knocker."  A  doc- 
tor in  an  inland  town  recently  told  me  of  a  fellow-practitioner  with 
whom  no  other  doctor  in  the  vicinity  would  consult  because  of  his 
unfair  dealings.  His  aim  seemed  to  be  to  disparage  the  abilities  and 
methods  of  others.  To  my  knowledge  that  particular  "knocker"  has 
already  moved  twice. 

"The  Principles  of  Medical  Ethics,"  recently  placed  in  your  hands 
through  the  courtesy  of  the  American  Medical  Association,  indicate  the 
correct  line  of  conduct  toward  patients,  fellow-practitioners,  and  the 
community,  and  though  they  are  intended  to  be  advisory  merely  they 
are  well  deserving  of  thoughtful  study  and  adoption. 

It  is  not  supposed  that  any  of  you  have  taken  up  the  profession  of 
medicine  as  a  money-making  business.  If  so,  there  are  more  than  nine 
chances  in  ten  that  you  will  be  disappointed.  You  should,  and  doubtless 
will,  obtain  a  competent  living,  and  earn  much  more  for  which  you  will 
receive  your  reward  in  the  hereafter.  You  will  sometimes  have  to  be 
satisfied  without  even  the  gratitude  of  patients  to  whom  you  shall  have 
rendered  valuable  services.  It  will  be  gratifying  to  find,  however,  that 
most  people  expect  to  pay  for  value  received.  Follow  the  Golden  Rule 
in  your  conduct  and  you  will  usually  be  treated  in  like  manner.  Ek) 
not  be  cast  down  if  you  should  learn  that  your  patients  have  consulted 
a  rival.  It  may  be  that  even  at  that  moment  some  of  your  rival's 
patients  are  on  their  way  to  consult  you.  Be  just  to  yourself.  You 
need  not  expect  to  satisfy  everybody  or  anybody  always.  Your  individ- 
uality, if  you  have  any,  will  not  make  it  possible.  Be  dignified.  Place 
a  proper  estimate  upon  your  own  services  and  do  not  underrate  them 
by  beating  down  your  colleague's  fees.  Remember  that  you  can  never 
build  yourself  up  on  a  substantial  foundation  by  in  any  manner  under- 
mining any  other  person,  be  he  physician  or  layman. 

There  has  sprung  up  during  the  past  few  years  the  practice  of 
"dividing  fees."  It  is  essentially  a  brokerage  business,  and  is  on  a 
par  with  the  practices  of  "runners"  in  "bath  cities."  Inasmuch  as  the 
entire  transaction  is  done  without  the  knowledge  of  and  nevertheless 
at  the  expense  of  the  patient,  it  becomes  unscrupulous  and  ends  in  a 
skin  game.  The  physician,  who  treats  or  examines  and  refers  a  patient 
to  a  specialist,  should  collect,  for  services  rendered,  from  the  patient 
himself  and  not  from  the  consultant,  and  the  specialist  should  not 
exhaust  the  patient's  ability  to  pay  the  first  physician's  bill.  This 
arrangement  is  natural,  honorable,  and  equitable  to  all  concerned,  while 
graft-seeking  and  bribe-giving  easily  descend  to  a  traffic  in  human  lives. 

Lastly  do  not  be  a  curiosity  shop.  Be  alive  to  and  interested  in 
everything  that  attracts  most  men.    Be  public  spirited.    Be  a  politician 


LESSONS  IN  LONGEVITY.  245 

if  duty  requires,  but  remember  that  a  busy,  successful  physician  and  a 
politician  are  never  one  and  the  same  person.  Your  profession  must 
be  your  first  and  chief  occupation — ^your  true  vocation.  That  does  not 
mean,  however,  that  you  should  not  have  an  avocation  as  well.  Take 
time  to  live.  You  owe  it  to  yourself,  to  your  family,  friends,  everybody. 
The  time  has  now  come  to  say  to  you  as  students.  Farewell,  but  by 
your  leave  I  will  say  instead,  Welcome,  members  of  a  noble  profession. 
We  wish  you  Godspeed. 

MEMOIRS. 

LESSONS  IN  LONGEVITY.* 

By  JOHN  S.  CAULKINS,  M.  D.,  Thornville,  Michigan. 
FIRST  PAPER. 

Many  physicians  know  that  the  writer  of  this  paper  is  very  old,  and 
some  know  that  his  era  dates  back  to  1822,  the  long  stretch  of  eighty- 
three  years  lying  behind  him.  From  the  knowledge  of  this  fact  an 
expectation  has  arisen  that  he  ought  to  have  something  to  say  relative 
to  old  age  which  might  have  a  modicum  of  value.  This  feeling  is 
doubtless  stimulated  by  the  observation  of  another  fact,  which  contem- 
plates the  retention  of  a  degree  of  vigor  and  activity  (physically  at 
least)  perhaps  somewhat  greater  than  usually  falls  to  the  lot  of  those 
who  reach  his  advanced  age.  Therefore,  in  compliance  with  repeated 
requests  this  paper  has  been  prepared  and  is  submitted  for  what  it  is 
worth.  What  is  to  be  said  on  the  subject  will  be  formulated  under 
these  two  heads : 

(i)  Is  it  desirable  to  attain  the  age  of  eighty-three  years? 

(2)  If  so,  how  is  that  objective  point  to  be  reached? 

For  lack  of  time  only  the  first  question  will  be  considered  today, 
the  second  being  reserved  for  subsequent  papers. 

Is  it  desirable  to  attain  the  age  of  eighty-three  years?  This  ques- 
tion is  to  be  considered  from  two  points  of  view — ^the  personal  and  the 
sociological,  and  viewed  from  either  the  answer  depends.  It  is  the 
surroundings  that  must  determine.  Aside  from  the  instinctive  clinging 
to  life,  which  is  natural  to  most  of  the  human  race,  a  rational  and  dis- 
passionate view  would  lead  one  to  answer  this  question  in  the  negative, 
and  to  add  that  there  cannot  be  much  left  to  tie  an  octogenarian  to 
earth.  Youthful  friends  and  associates  have  one  by  one  gone  and  left 
him,  and  he  is  "a  pilgrim  and  a  stranger."  Things  in  this  world  being 
so  unevenly  divided  there  is  for  the  most  want  and  poverty  to  be 
endured,  while  infirmities  of  age  being  many,  there  is  pain  to  suffer. 
All  this  for  the  very  old  makes  life  not  worth  living.  There  are,  of 
course,  exceptions  to  this.    Where  a  temperate  and  well-spent  youth 

*A  paper  read  before  the  Lapeer  County  (Michigan)  Medical  Society  by  its 
oldest  member. 


246  ORIGINAL  ARTICLES. 

and  middle  age  have  stored  up  a  reserve  of  health  and  vigor ;  where 
there  yet  remains  a  good  degree  of  interest  in  things  and  events,  and 
there  is  money  enough  to  supply  all  reasonable  wants,  life  may  be  quite 
enjoyable  long  after  reaching  the  age  at  which,  according  to  Osier's 
new  gospel,  persons  should  be  chloroformed.'*'  It  is  an  old  proverb  that 
a  man  is  no  older  than  he  feels.  It  is  not  the  lapse  of  years  but  the 
breakdown  they  bring  that  counts. 

Examined  from  the  other  point  of  view,  that  of  the  community  in 
which  the  old  man  lives,  it  will  still  be  seen  that  the  answer  depends. 
If  he  can  yet  perform  some  useful  work  better  than  younger  men  he 
will  of  course  be  tolerated,  and  even  if  his  usefulness  is  over,  if  he  has 
money  enough  to  pay  his  way  he  will  be  accorded  tolerance ;  but  if  he 
is  helpless,  and  poor,  too,  very  little  interest  is  manifested  towards  him, 
however  useful  he  may  have  been  in  his  youth  and  manhood.  Society 
is  as  ruthless  in  this  humanitarian  age  regarding  the  treatment  of  the 
infirm  old  as  it  was  in  the  stone  age,  when  the  custom  prevailed  of 
killing  such  as  could  no  longer  take  care  of  themselves.  That  indeed 
looks  cruel  to  us  and  we  are  apt  to  shudder  at  such  barbarity,  but  a  little 
reflection  will  demonstrate  that  it  was  not  invariably,  and  probably  not 
generally,  barbarity  which  caused  the  act,  but  that  a  stem  necessity  of 
the  savage  state  compelled  it,  and  sometimes  made  the  apparently  mer- 
ciless procedure  one  of  the  greatest  humanity  possible.  Suppose  a  case 
where  winter  was  at  hand  and  provisions  were  scarce.  The  tribe  must 
migrate  and  find  some  place  where  hunting  and  fishing  are  better,  and 
the  long  journey  must  be  made  on  foot.  What  must  be  done  with  the 
lame,  sick,  and  bedridden?  The  choice  lies  between  leaving  them  to 
die  of  hunger  or  to  the  still  more  horrible  fate  of  being  eaten  alive  by 
wolves,  or  giving  them  the  "happy  dispatch."  Certainly  humanity  dic- 
tates the  latter,  and  the  victim  himself  having  always  anticipated  the 
inevitable  end,  unless  war  or  accident  intervened,  and  having  served 
his  father  the  same  way,  would  invoke  his  barbarian  fortitude  and 
willingly  submit  to  his  fate. 

Methods  vary  but  results  are  about  the  same  in  every  age.  The 
primitive  method  has  much  to  recommend  it.  It  is  quick  and  easy.  One 
bounce  on  the  head  with  a  big  stick  in  muscular  hands,'  one  sharp,  short 
pain,  one  quiver  and  the  old  grandfather  was  off  to  the  happy  hunting 
grounds,  and  the  bread  he  would  have  eaten  helps  to  feed  the  grand- 
children through  the  winter. 

We  no  longer  use  the  club  or  any  similar  instrument  to  "shuffle 
off"  incapables,  but  we  confine  them  in  houses,  generally  unsanitary, 
where  the  minimum  amount  of  care  and  comfort  is  found  and  let  them 

'^This  allusion  to  Osier  is,  like  what  he  himself  said  in  his  valedictory  at 
Johns  Hopkins,  merely  jocular.  Perhaps  no  little,  casual  utterance  ever  made 
such  a  commotion  in  a  community  as  that.  Every  magazine  and  paper  has  had 
its  fling  at  it  and  its  author,  and  most  of  them  have  made  the  mistake  of  taking 
him  seriously.  That  he  was  very  wrong  in  the  assertion  will  be  shown  further 
on,  some  good  having  been  done,  with  the  most  far>reaching  good  results,  after 
seventy  and  eighty  were  past 


LESSONS  IN  LONGEVITY.  247 

live  as  long  as  they  can.  Very  little  interest  is  felt  in  them  and  they 
are  not  missed  when  dead.  In  our  present  imperfect  state  of  human 
society  we  cannot  look  for  anything  else.  It  is  the  law  of  Nature  that 
whatever  is  born  must  grow  old  and  die,  and  the  law  is  necessary  and 
beneficent,  for  otherwise  the  earth  would  become  overcrowded  and 
unable  to  support  its  inhabitants.  The  unavoidable  conclusion  follows 
that  the  old  must  give  place  to  the  young,  since  the  natural  rights  of 
every  human  being  are  equal.  The  old  have  had  their  turn,  and  it  is 
proper  that  they  should  not  stand  in  the  way  of  those  who  come  after 
them.  Since  this  is  so,  it  is  not  strange  that  many  who  have  the  care 
of  the  very  old  grow  indifferent  to  their  want  of  comfort,  and  look  at 
them  as  a  burden  of  which  they  would  gladly  be  rid.  This  indifference 
is  not  unfrequently  felt  by  its  victims  so  acutely  that  a  resort  to  suicide 
is  the  only  way  to  escape  from  the  intolerable  condition. 

Concluding  this  part  of  our  discussion  we  repeat  what  was  said  at 
the  outset,  that  the  answer  to  the  query,  "Is  it  desirable  to  live  eighty- 
three  years?"  is  dependent  on  the  surroundings  of  each  individual, 
adding  the  remark  that  probably  with  the  most  of  those  who  reach  that 
advanced  age  it  is  wholly  undesirable. 

We  will  now  discontinue  the  discussion  in  this  pessimistic  way,  and 
from  a  wider  point  of  view  look  at  it  as  applicable  to  the  whole  human 
family,  and  restate  the  question  like  this :  "Is  it  desirable  that  the  aver- 
age duration  of  human  life  on  our  planet  should  be  made  longer  than 
it  now  is  ?"  Stated  this  way  the  unanimous  answer  will  be  in  the  affirm- 
ative, and  we  may  add  that  it  is  not  only  desirable  but  necessary  and 
indispensable  if  the  world  is  ever  to  be  rid  of  the  evils  by  which  it  at 
present  is  infested.  Ignorance  is  the  evil  and  the  mother  of  evils.  Her 
children  are  poverty,  crime,' war,  and  pestilence,  and  there  is  mutual 
reaction  between  them  tending  to  enlarge  the  circle  of  malign  influence 
of  which  each  is  the  center.  There  is  a  remedy  for  every  evil  caused  by 
ignorance.  This  none  can  be  stupid  or  inconsequent 'enough  to  deny. 
The  remedy  is  the  discovery  of  scientific  truth  and  its  application  to  the 
affairs  of  men :  the  discovery  of  the  true  laws  of  Nature  and  obedience 
to  them,  whether  physical,  mental  or  moral.  Truth  is  in  her  well  and 
must  be  hunted  for  and  drawn  from  its  recesses.  This  needs  time, 
which  we  do  not  have  in  our  short  term  of  life — our  three  score  years 
and  ten.  The  years  for  doing  good  work  are  too  few.  We  must  stop 
and  die  before  our  plans  are  half  executed.  The  time  for  study  being 
so  limited  progress  is  slow.  Some  say  that  nothing  of  real  value  is 
performed  after  sixty  is  reached.  There  is  reason  to  believe  this  limit 
an  underestimate,  but  we  must  admit  that  the  time  is  very  short  at  the 
best.  There  is  a  great  loss  where  one  man  has  to  take  up  the  unfinished 
work  of  another.  He  cannot  begin  right  where  the  other  left  off,  but 
must  go  through  all  the  preliminary  work  that  his  predecessor  has 
already  mastered.  It  is  a  great  waste  and,  besides,  not  very  safe. 
Youth  is  available  in  adventuring  into  new  paths  and  noting  new  facts, 


£i8  ORIGINAL  ARTICLES. 

but  is  too  volatile,  self-conceited,  quarrelsome  and  vindictive  to  do 
anything  but  one-sided  work.  The  effervescence  and  querulousness  of 
youth  must  subside  and  be  replaced  by  the  calm  modesty  of  the  sage 
and  philosopher  who  has  burned  the  midnight  oil  in  his  search  for  the 
truth  till  it  stands  irrefutable  and  apparent  to  every  inquirer. 

Suppose  the  short  working  period  doubled.  It  would  far  more  than 
double  our  product.  Instead  of  our  present  slow  progress  the  potential 
of  human  endeavor  would  increase  in  geometrical  proportion.  When 
the  time  arrives  that  the  octogenarian,  instead  of  being  counted  as  at 
present,  hardly  belonging  to  the  living,  but  looked  askance  at  as  merely 
a  wreck  or  derelict  on  the  ocean  of  time,  will  be,  as  the  Germans  say, 
in  his  best  years,  then  this  earth  will  be  a  good  place  in  which  to  live  out 
a  long  lite.  The  remedies  for  poverty  and  crime  will  be  found,  wars 
will  cease  and  be  replaced  by  arbitration,  and  the  cause  of  every  disease 
will  be  hunted  down  and  stamped  out,  old  age  included,  which,  accord- 
ing to  the  discoveries  of  Metschnikoff  is,  like  the  most  of  human  ills, 
a  microbic  disease  and  can  no  doubt  like  the  rest  be  avoided. 

It  has  been  truly  said  that  no  chain  is  stronger  than  its  weakest 
link.  But  why  have  a  weak  link  in  the  chain.  Let  the  smith  look  to  his 
work  and  make  every  link  out  of  the  same  flawless  iron  and  every  weld 
perfect  and  then  there  would  be  no  break  anywhere,  the  chain  would 
hold  all  the  team  could  draw,  and  all  would  wear  out  together,  like  the 
''one  boss  shay."  Lives  are  the  links  in  the  chain  of  human  existence, 
and  although  most  of  these  links  are  very  weak  there  are  now  and  then 
notable  exceptions  that  have  grown  up  with  sufficient  cellular  stability 
to  outlast  three  or  four  ordinary  lives.  These  exceptional  cases  have 
of  course  reasons  and  causes  that  account  for  them  since  every  result 
is  the  effect  of  a  cause,  and  the  uniformity  of  Nature's  laws  teaches  us 
that  like  causes  produce  like  effects.  What  man  has  done  man  may  do. 
It  is  the  business  of  the  philanthropist  and  philosopher  to  study  and 
learn  what  these  causes  are  as  fast  as  possible  and  teach  them  to  the 
rest  of  mankind.  Some  work  has  already  been  done  along  this  line, 
more  is  being  done,  and  much  remains  to  be  done. 

It  is  to  be  expected  that  here  the  pessimist  will  step  forward  to  urge 
that  it  is  Chimerical  to  believe  that  lengthening  the  span  of  human  life 
can  have  any  good  influence  toward  lessening  the  sum  of  our  ills  but 
might  instead  prove  a  damage  by  lengthening  the  term  of  the  undesir- 
able classes,  the  criminals,  and  weaklings,  equally  with  the  best.  This 
is  easily  answered.  It  is  equivalent  to  asserting  that  there  is  no  human 
progress,  and  we  know  there  is.  The  race  has  always  followed  the 
best  light  it  had,  otherwise  we  would  still  be  wandering  savages  like  our 
ancestors  of  the  stond  age.  Poverty  is  the  prolific  mother  of  most 
crimes  and  they  will  die  with  their  mother,  and  as  for  the  weaklings 
who  now  mostly  die  in  infancy,  if  they  live  to  grow  up,  it  will  not  be  to 
propagate  their  own  degeneracy.  Among  the  discoveries  of  the  future 
there  will  be  one  for  the  humane,  easy,  painless  and  complete  steriliza- 


LESSONS  IN  LONGEVITY.  249 

tion  of  such  as  are  not  fit  to  propogate  the  species.  Why  should  not 
man  be  improved  by  applying  to  him  the  methods  that  govern  improve- 
ment in  other  animals  ?  It  would  puzzle  anyone  to  say  why  not.  Suppose 
this  work  done  and  the  improvement  of  the  animal  Man  placed  on  a 
sound  and  strictly  scientific  basis,  what  would  the  result  show  his  nat- 
ural term  of  life  to  be  ?  The  other  animals  have  a  limit  at  which,  if 
they  escape  disease  and  violence,  they  die  from  sheer  old  age,  their 
stock  of  vitality  being  exhausted.  It  is  not  likely  that  the  genus  homo 
is  an  exception  to  the  rule.  Several  students  of  nature  have  treated  this 
subject,  basing  their  conclusions  on  comparisons  between  man  and  other 
animals  relative  to  the  ratio  between  the  whole  length  of  life  and  the 
period  of  certain  stages  of  it,  such  as  gestation,  dentition,  lactation,  and 
growth,  the  last  attracting  the  most  attention.  Comaro,  in  Italy, 
Buffon,  the  naturalist  of  France,  and  Hufeland  of  Germany  have  writ- 
ten on  this  subject,  the  latter  the  most  elaborately.  His  book,  "Macro- 
biotik,"  has  been  translated  into  all  the  European  languages  and  into 
several  Asiatic.  Of  these  three,  Comaro  only  contends  for  a  hundred 
years,  Buffon  for  one  hundred  and  forty,  but  Hufeland  says,  page  149 
(Erasmus  Wilson's  edition),  "We  may  with  the  greatest  probability 
assert,  that  the  organization  and  vital  power  of  man  are  able  to  support 
a  duration  and  activity  of  two  hundred  years."  He  goes  on  to  say, 
"This  assertion  acquires  some  weight  by  our  finding  that  it  agrees  with 
the  proportion  between  the  time  of  growth  and  the  duration  of  life. 
One  may  lay  it  down  as  a  rule  that  an  animal  lives  eight  times  as  long 
as  it  grows.  Now,  man  in  his  natural  state,  where  the  period  of  matur- 
ity is  not  hastened  by  art,  requires  full  twenty-five  years  to  attain  his 
complete  growth  and  conformation,  and  this  proportion  will  give  him 
an  absolute  age  of  two  hundred  years."  Chapter  V  of  his  book  (first 
part)  is  devoted  to  instances  of  long  life,  considered  by  countries  and 
professions.  He  says  the  medical  makes  the  poorest  showing  among 
the  professions.  In  a  table  which  he  gives  of  the  ages  of  distinguished 
physicians  there  is  only  one  above  the  one  hundred  mark.  It  is  the 
name  of  our  great  founder,  Hippocrates.  He  says,  page  25,  "Mortality 
is  greater  among  practical  physicians  than  perhaps  among  men  of  any 
other  profession.  *  *  *  The  greatest  mortality  prevails  during 
the  first  ten  years  of  practice.  *  *  *  A  physician  who  has  luckily 
passed  his  time  of  probation  may  become  an  old  man." 

This  paper  is  quite  long  enough  for  the  first  of  the  series,  and  the 
discussion  will  be  dropped  now  with  the  understanding  that  it  shall 
be  resumed  later.  I  may  as  well  admit  that  besides  willingness  to 
please,  by  complying  with  your  repeated  requests  for  the  paper,  there 
was  a  little  "motif"  of  my  own  hidden  behind  its  preparation,  and 
here  it  is.     You  remember  Robbie  Burns'  lines: 

"O  wad  some  power  the  giftie  gie  us, 
To  see  oursel  as  ithers  see  us. 
It  wad  frae  mony  a  blunder  free  us 
And  foolish  notion." 


250  ORIGINAL  ARTICLES. 

It  goes  without  saying  that  the  old  man  is  not  in  so  good  condition 
to  sec  "himsel"  as  "ithers"  see  him  as  a  young  man  would  be,  and  as  he 
comes  nearer  to  the  jumping-oflF  place  he  gets  less  and  less  fit  for  the 
effort.  It  is  not  prudent  to  skate  too  far  out  on  the  ice  of  which  one 
does  not  know  the  strength  and  thickness:  better  stop  and  see  if  it  is 
safe  for  fear  one  will  come  to  grief  in  the  cold  water.  There  is  a 
stopping  place  somewhere  just  ahead  and  sometime  everyone  will  find 
it,  and  how  is  the  old  man  to  know,  since  he  cannot  see  for  himself, 
when  he  has  reached  the  spot.  Evidently  there  is  no  way  but  to  make 
a  little  trial  and  watch  the  result.  This  paper  is  an  effort  in  that  direc- 
tion. If  an  unfavora))le  impression  has  been  created,  serve  the  writer 
as  the  old  Romans  did  their  wounded  and  inefficient  gladiators, — ^tum 
down  your  thumbs  and  put  him  out  of  his  misery. 

[to  BB  COMTINVBD.] 


EXPERIENCE  WITH  STATIC  ELECTRICITY.* 
By  NEIL  A.  GATES.  M.  D.,  Dexter,  Michigan. 

It  is  not  my  intention  to  delve  into  ancient  history  and  dilate  on  the 
antiquity  of  static  electricity  as  a  factor  in  the  treatment  of  disease  con- 
ditions, but  simply  to  report  a  few  cases  from  an  experience  extending 
over  the  past  seven  years,  and  endeavor  to  demonstrate  that  this  thera- 
peutic agent  is  not  to  be  regarded  with  indifference  by  the  general  practi- 
tioner. It  may  not,  however,  be  amiss  to  say  that  from  the  year  1750, 
when  it  was  first  introduced  into  medicine,  it  has  made  rapid  strides  in 
advancement,  until  in  the  year  1905,  when  by  being  the  best  electrical 
means  of  exciting  a  vacuum  tube  for  jr-ray  work,  it  has  become  not  an 
expensive  luxury  but  an  absolute  necessity,  and  even  the  humblest  of 
practitioners  cannot  afford  to  be  without  its  valuable  aid.  It  is  a  means 
which  we  should  all  employ  rather  than  relinquish  to  the  practice  of 
specialists.  The  startling  results  achieved  with  electricity  in  relieving 
aches  and  pains  and  in  the  treatment  of  a  large  proportion  of  nerv- 
ous ailments  due  to  our  strenuous  and  unnatural  mode  of  life,  render 
the  static  machine  an  important  acquisition  to  the  armamentarium  of  the 
successful  physician. 

In  this  paper,  owing  to  lack  of  time,  I  will  confine  my  remarks  to 
the  treatment  of  disease  conditions  by  static  electricity  alone,  although 
I  am  well  aware  that  since  its  entrance  into  the  interesting  and  wonder- 
ful field  of  jr-ray  work  its  past  usefulness  seems  to  have  been  over- 
shadowed and  left  in  the  hands  of  a  few.  To  be  successful,  there  are 
some  duties  we  owe  to  our  machine  and  many  points  we  must  always 
bear  in  mind. 

We  must  have  a  reliable  machine,  large  enough  to  obtain  good 
results.  A  great  percentage  of  those  who  have  tried  static  electricity 
and  reaped  disappointment  must  ascribe  failure  to  small  and  cheap 
machines.      There   are   many   firms   now   making   machines    which, 

*Read  before  the  Washtenaw  County  (Ann  Arbor)  Medical  Society. 


STATIC  ELECTRICITY.  261 

although  they  present  a  fine  appearance  in  the  office,  are  practically 
worthless,  for,  by  reason  of  cheap  construction,  they  will  not  work  in 
all  conditions  of  weather  and  soon  wear  out  even  under  the  most  favor- 
able treatment.  I  can  readily  see  how  a  brother  practitioner,  having 
obtained  one  of  these  machines,  soon  becomes  discouraged  and  con- 
vinced that  the  usefulness  of  static  electricity  is  confined  to  the  good 
impression  a  patient  receives  by  being  treated  with  so  large  and  for- 
midable an  apparatus.  That  this  is  erroneous,  and  that  static  electricity 
penetrates  to  the  deeper  organs  and  cures,  not  by  hypnotizing,  but  by 
relieving  inflammatory  conditions,  I  shall  endeavor  to  prove. 

To  get  the  best  results  one  must  have  a  suitable  room  and  sur- 
roundings, generally  the  more  room  around  the  platform  the  better, 
and,  most  essential  of  all,  two  good  ground  wires.  With  a  modem 
machine,  given  a  little  attention  each  day,  one  can  use  it  with  the  best 
of  results  every  day  in  the  year. 

Physicians  must  study  patients.  We  all  know  that  electricity  of  any 
kind  is  very  disagreeable  to  some  patients,  but  by  carefully  giving  a 
short  treatment  with  static  insulation,  and  then  following  with  the 
static  breeze,  demonstrating  that  the  patient  is  not  to  be  subjected  to 
sudden  shocks,  the  benefit  derived  will  soon  convince  each  that  he  is 
on  the  road  to  health,  and  the  operator  will  be  surprised  to  learn  that 
these  timid  patients  soon  withstand  a  long  spark  and  even  insist  upon 
having  it,  the  relief  from  pain  being  so  great  that  any  inconvenience 
for  the  moment  is  soon  forgotten.  One  will  learn  that  a  patient  will 
readily  take  treatment  when  he  finds  that  it  is  unnecessary  to  remove 
any  part  of  his  clothing.  Think  of  the  saving  of  time  to  a  busy  prac- 
titioner when  a  patient  comes  from  the  street  and  without  delay  steps 
upon  the  platform,  receives  treatment  and  departs  without  removing 
and  replacing  wearing  apparel. 

One  must  also  lake  into  consideration  the  material  of  the  patient's 
clothing,  whether  woolen  or  cotton,  and  remember  where  pins  and 
steels  are  likely  to  be  concealed.  In  giving  treatments  one  must  always 
exercise  the  greatest  care  not  to  unnecessarily  alarm  the  patient  by 
accidentally  touching  him  or  placing  him  too  near  objects  in  the  room. 
This  is  especially  true  if  the  patient  is  dressed  with  woolen  clothes. 

A  great  many  operators  recognize  no  difference  between  the  posi- 
tive and  negative  poles  of  the  machine.  This  is  a  great  mistake,  for 
the  positive  pole  acts  as  a  stimulant  and  the  negative  as  a  sedative. 
This  refers  to  general  electrification  only,  for  in  the  employment  of 
the  breeze  and  spark  the  reverse  is  true.  A  physician  can  readily  see 
that  he  must  understand  the  condition  of  the  patient  as  well  as  the 
machine,  and  I  will  add  that  the  better  one  attends  to  these  details  the 
better  will  be  the  result. 

Without  consuming  more  time  in  explaining  the  diflferent  forms 
of  treatment,  I  will,  by  reporting  the  history  of  a  few  selected  cases, 
endeavor  to  show  the  various  forms  of  treatment  I  adopt  in  different 


252  ORIGINAL  ARTICLES. 

cases  and  the  startling  results  I  obtain,  which,  I  am  sure,  all  practi- 
tioners will  agree  could  not  be  attained  with  drugs. 

Case  I. — A  tailor,  age  thirty-six.  From  the  effects  of  overwork 
patient  was  nervous,  run  down,  and  troubled  with  insomnia,  having 
severe  headaches  and  nausea.  One  night  after  a  hard  day's  work  over 
a  gas-heated  iron,  the  fumes  from  which  were  overpowering,  this  man 
closed  his  shop,  being  unable  to  work  longer.  He  came  into  my  office 
and  after  a  careful  examination  I  placed  him  on  the  platform  con- 
nected to  the  negative  pole  of  the  machine,  grounded  the  positive  pole, 
and  to  this  attached  a  brass-pointed  electrode.  I  then  started  the 
machine  and  slowly  moved  the  electrode  (keeping  it  about  six  inches 
from  patient)  up  and  down  his  back,  over  his  head,  and  finally  down 
in  front  of  him,  letting  it  come  to  a  stop  in  such  a  manner  that  I  could 
get  a  strong  breeze  over  the  region  of  his  stomach.  I  continued  this 
treatment  ten  minutes.  The  patient  then  left  the  office,  opened  his 
shop,  and  worked  three  more  hours  without  any  discomfort.  Pursuing- 
this  case  I  gave  patient  daily  treatments  of  ten  minutes  each  for  two 
weeks,  when  they  were  discontinued,  being  firmly  convinced  that  he 
had  entirely  recovered,  and  time  proved  the  correctness  of  this  convic- 
tion. 

Case  IL — A  merchant  came  to  me  complaining  of  insomnia. 
Patient  had  been  subjected  to  considerable  mental  strain  for  the  past 
six  weeks  owing  to  business  difficulties.  The  effect  was  a  nervous 
affliction  manifesting  itself  in  severe  insomnia.  A  brother  practitioner 
had  advised  a  vacation  with  a  trip  to  the  seashore,  but  this  was  impos- 
sibe  for  many  reasons.  Physical  examination  disclosed  nothing  but 
extreme  emaciation  and  weakness.  I  advised  a  system  of  potential 
alternation  treatments,  which  allowed  the  patient  to  continue  the 
administration  of  business  affairs,  an  absolute  necessity.  Patient  came 
to  my  office  evenings  after  closing  his  store.  I  placed  him  on  the  plat- 
form and  grounded  the  negative  pole  which  was  attached  to  the  head 
crown  electrode.  I  connected  the  positive  pole  of  the  machine  to  the 
platform  and  also  attached  it  to  a  copper  plate  placed  under  the  patient's 
feet.  Before  administering  this  treatment  I  either  had  the  patient 
remove  his  shoes,  or  placed  several  thicknesses  of  paper  between  elec- 
trodes and  soles  of  shoes  as  bare  shoes  coming  in  contact  with  elec- 
trodes will  cause  an  unpleasant  sensation  to  the  feet,  annoy  the  patient, 
and  counteract  the  good  effect  of  the  treatment.  Next  I  took  a  long 
chain  connected  to  a  separate  ground  wire  and  attached  it  to  a  brass 
ball  electrode  held  by  a  holder.  Then  I  placed  the  brass  ball  from  one 
to  three  inches  (as  this  case  required)  from  the  electrode  connecting 
the  positive  pole  to  the  platform,  and  started  the  machine,  the  spark 
gape  between  electrode  and  brass  ball  being  guaged  to  suit  the  patient. 
I  continued  the  treatment  for  ten  minutes.  The  patient  went  home  and 
had  a  good  night's  rest,  sleeping,  as  he  said,  more  profoundly  than  he 
had  in  a  month.     Patient  took  similar  treatments  nightly  for  three 


STATIC  ELECTRICITY.  263 

weeks,  when  all  symptoms  disappeared,  and  he  had  gained  four  pounds 
in  weight,  felt  free  from  worry,  and  was  entirely  well.  I  will  add  that 
I  have  used  this  form  of  treatment  in  many  cases  and  consider  it 
the  best  tonic  sedative.  I  have  often  had  patients  enter  the  condition 
of  sleep  during  the  treatment,  and  have  never  experienced  failure  to 
cure  insomnia. 

Case  III. — A  housewife,  age  thirty,  mother  of  four  children,  had 
slight  laceration  of  cervix  and  perineum.  She  complained  of  dragging 
pain  in  pelvis,  backache,  headache,  and  nervousness,  the  latter  symp- 
tom being  so  pronounced  that  she  feared  loss  of  mind.  I  advised  oper- 
ation for  repair  of  cervix  and  perineum,  which  was  done,  but  without 
improvement  of  condition.  Patient  complained  more  after  the  good 
effects  of  a  much-needed  rest,  which  the  operation  necessitated,  wore 
off.  I  then  employed  the  static  breeze  as  in  Case  I,  limiting  the  breeze 
more  especially  to  pelvis,  back,  and  head.  Three  weeks'  treatment 
effected  a  cure,  and  now,  after  two  years,  there  is  no  return  of  the 
symptoms. 

Case  IV, — A  lumberman,  fifty  years  old.  He  suffered  occasional 
attacks  of  lumbago  for  eight  years.  When  I  was  called,  patient  had 
been  confined  to  bed  two  weeks,  being  unable  to  turn  over  without 
assistance.  His  doctor  had  been  administering  salicylate  of  soda  inter- 
nally, with  counterirritants  to  back,  and  relieving  pain  with  daily 
hypodermics  of  morphin.  Much  to  the  disbelief  of  patient's  friends 
and  himself  I  informed  him  that  I  could  do  nothing  further  for  him  at 
his  home,  but  that  if  he  could  get  to  my  office  I  would  cure  him  in  two 
minutes.  Although  the  patient  could  not  believe  it  possible,  after  strong 
urging,  I  induced  him  to  consent  to  the  transfer.  A  great  deal  of  per- 
suasion was  necessary  to  influence  a  man  in  his  condition  to  drive  one 
mile,  but  after  placing  a  cot  in  a  spring  wagon  and  conveying  the  patient 
thereto,  the  start  was  finally  made.  It  was  in  the  fall  of  the  year,  when 
the  roads  were  rough,  and  after  going  a  few  rods  patient  insisted  on 
getting  out  of  the  vehicle,  and,  with  the  help  of  crutches  and  my  assist- 
ance, walked  the  rest  of  "the  journey.  After  a  short  rest  I  laboriously 
placed  him  on  the  platform  of  the  machine  and  administered  a  six-inch 
positive  spark,  obtained  by  connecting  the  platform  with  the  negative 
pole,  grounding  the  positive  pole,  the  electrode  being  connected  to  the 
ground  wire.  I  administered  the  sparks  with  the  patient  standing,  as 
it  was  impossible  for  him  to  sit.  In  about  two  minutes  I  discontinued 
the  current  and  requested  him  to  step  off  the  platform.  Much  to  his 
surprise  and  gratification  he  did  so,  and  found  that  he  could  bend 
forward  and  place  his  hands  upon  the  floor  without  any  discomfort. 
After  the  patient  had  walked  around  a  bit  I  again  administered  mild 
sparks  for  ten  minutes,  and  I  can  truthfully  say  that  during  the  last 
four  years  he  has  not  had  a  symptom  of  lumbago.  This  may  seem  an 
exaggerated  case  but  I  can  give  assurance  that  it  is  not,  and  anybody 


254  ORIGINAL  ARTICLES. 

accustomed  to  the  moderate  use  of  static  electricity  has  had  many 
similar  experiences. 

It  is  needless  to  say  that  the  patients  this  particular  case  has  brought 
me  would  pay  for  a  great  many  static  machines.  I  have  treated  many 
cases  of  lumbago  and  other  forms  of  muscular  rheumatism,  and  where 
I  can  use  a  six-inch  spark  I  never  fail  to  give  instant  relief.  In  cases 
where  the  patient  will  not  tolerate  the  spark  the  positive  breeze  will 
surely  effect  a  cure,  although  longer  time  will  be  required. 

Case  V. — A  furniture  dealer,  age  forty-two.  After  sustaining  a 
wrench  of  the  shoulder,  followed  by  rheumatic  pains,  this  man  con- 
sulted me  regarding  a  partial  paralysis  of  his  right  arm.  On  examina- 
tion I  found  almost  a  complete  atrophy  of  the  trapezius,  deltoid  and 
infraspinatus  muscles.  I  connected  the  patient  to  the  machine  in  order 
to  obtain  the  induced  static  current,  using  the  smallest  Leyden  jar  I 
had.  Patient  was  requested  to  hold  one  electrode  in  his  left  hand  while 
the  other  was  placed  to  his  shoulder  outside  clothing.  I  then  started 
the  machine  slowly,  and  for  five  minutes  caused  feeble  contraction  and 
relaxation  of  these  muscles;  then  for  another  five  minutes  turned  the 
machine  rapidly,  using  the  current  as  a  massage.  This  treatment  was 
continued  for  four  weeks,  resulting  in  complete  cure  of  the  paralysis 
and  restoration  of  muscle  symmetry. 

Case  VI, — An  unmarried  woman  came  to  me  suffering  from  amen- 
orrhea and  accompanying  symptoms  which  I  diagnosed  as  chlorosis.  I 
gave  the  patient  daily  treatments  of  positive  insulation  continued  for 
ten  minutes  and  accompanied  by  a  negative  breeze  to  the  pelvis.  In 
three  weeks  the  patient  was  discharged  well. 

Case  VII. — A  married  woman  consulted  me  for  a  badly  sprained 
wrist  following  a  fall.  There  was  no  fracture  or  dislocation  of  the 
bones.  I  treated  the  wrist  daily  with  static  breeze,  with  the  result  that 
swelling  and  soreness  subsided  within  a  week. 

Case  VIII. — An  unmarried  woman  sought  relief  from  a  distressing 
acne  indurata.  I  employed  the  positive  breeze  on  her  face,  using  a 
wooden  electrode.    Three  weeks  sui&ced  to  effect  a  cure. 

In  selecting  these  cases  for  report  I  purposely  picked  those  in  which 
no  drugs  were  used.  I  would  not  say  that  this  is  wise  in  every  instance, 
for  I  think  it  better  in  many  cases  to  employ  both.  The  results  show, 
however,  that  a  great  deal  can  be  accomplished  with  static  electricity 
alone.  I  do  not  wish  to  impart  the' impression  that  static  electricity  is 
a  cure-all,  for  it  is  not,  but  it  can  be  employed,  with  safety,  in  every 
case.  Nothing  will  relieve  the  pains  of  neuritis,  nervous  headache, 
and  the  vomiting  of  pregnancy  so  quickly  as  will  static  electricity. 

In  closing  I  will  add  the  assurance  that  from  my  own  experience, 
after  a  hard  day's  work,  nothing  is  more  refreshing  and  invigorating 
than  ten  minutes  application  of  the  static  breeze.    Try  it. 


CLINICAL  SOCIETY  265 

TRANSACTIONS. 


CLINICAL  SOCIETY  OP  THE  UNIVERSITY  OP  MICHIQAN. 

STATED  MEETING,  JANUARY  15,  1906. 

The  President,  WILLIAM  K.  LYMAN,  M.  D.,  in  the  Chair. 

Reported  by  DAVID  M.  KANE,  M.  D.,  Secretary.^ 

REPORT  OF  CASES. 

ADENOIDS, 

Doctor  William  R.  Lyman  :  I  do  not  intend  to  discuss  the  sub- 
ject of  adenoids  fully,  but  rather  to  report  some  observations  based 
upon  a  study  of  the  records  of  the  Otolaryngologic  clinic  at  the  Uni- 
versity Hospital  for  the  year  1905 ;  to  compare  them  briefly  with  our 
accepted  opinions;  to  call  attention  to  the  frequency  with  which  this 
disease  is  accompanied  by  serious  complications  and  to  emphasize  the 
importance  of  early  treatment. 

During  the  year  1905  there  were  examined  one  hundred  and  forty- 
five  cases  of  adenoids,  of  which  number  seventy-nine  also  had  chronic 
hypertrophy  of  the  faucial  tonsils;  in  fact,  in  many  cases  it  was  the 
tonsilar  condition  which  brought  the  patient  to  the  clinic  for  relief. 
Many  of  the  patients  were  college  students,  which  fact  is  of  importance 
in  the  interpretation  of  data  to  be  brought  forward  later.  As  to  sex 
there  were  ninety  males  and  fifty-five  females.  The  preponderance  of 
males  as  compared  with  other  statistics  is  explainable  by  the  fact  that 
this  clinic  draws  largely  from  the  student  body  for  its  material.  For 
purposes  of  convenience  the  following  tabulation  sets  forth  the  number 
of  patients  per  semidecade : 

From     1-5    years  old 9  From    5-10  years  old 39 

From  10-15  years  old 31  From  15-20  years  old 21 

From  20-25  years  old 31  From  25-30  years  old 8 

Over   30       years  old 6 

One  is  at  once  struck  by  the  small  number  of  cases  found  in  the  first 
semidecade  of  life,  during  which  period  we  are  informed  the  greatest 
number  of  patients  present  themselves  to  our  observation.  The  great- 
est number  of  any  single  semidecade  was  that  between  the  ages  of  five 
and  ten.  Fully  thirty-six  per  cent  of  our  cases  occurred  between  the 
ages  of  fifteen  and  twenty-five.  One  case  was  that  of  an  adult  fifty- 
seven  years  old.  These  figures  are  quite  at  variance  with  those  ordi- 
narily set  forth,  but  the  fact  admits  of  ready  explanation.  The  pres- 
ence of  nasopharyngeal  abnormalities  is  often  overlooked  by  the 
parents.  The  significance  of  adenoids  in  children  is  not  widely  or  fully 
appreciated  and  a  large  per  cent  of  the  patients  of  this  clinic  were  Uni- 
versity students,  which  latter  fact  alone  accounts  for  the  variation. 

Of  importance  is  the  time  of  year  during  which  the  greatest  number 
of  patients  presented  themselves  for  treatment.    The  records  for  April 


256  ORIGINAL  ARTICLES. 

and  May  show  an  enrollment  of  thirty-five  cases,  which  suggest  the 
relationship  of  adenoids  to  the  nasopharyngeal  disturbances  so 
frequent  in  early  spring.  The  patients  in  general  complained  of 
the  classical  symptoms  of  the  condition— difficult  nasal  re^iration, 
mouth-breathing  with  its  characteristic  facial  expression,  and,  to 
quote  Doctor  Schadle,  "The  open  mouth,  the  pinched  nose,  the 
drawn  down  inner  canthi,  elevated  eyebrows,  corrugated  skin  of  the 
forehead,  the  distorted  chest,  the  altered  voice,  the  apparent  defective 
development — ^both  mental  and  physical."  There  may  be  added :  pro- 
truding upper  teeth,  and  high  palatal  arch;  repeated  attacks  of  sore 
throat,  which  is  generally  due  to  the  associated  tonsilar  hypertrophy ; 
a  fullness  and  the  sensation  described  as  something  dropping  in  the 
back  of  the  throat ;  a  seromucoid  discharge  from  the  nostrils ;  the  state- 
ment of  the  parent  that  the  child  is  apparently  aflFected  with  a  continu- 
ous cold  in  the  head ;  a  voice  thick  aq^  without  resonance,  such  letters 
as  m  and  n  not  being  pronounceable ;  and,  frequently,  palpability  of  the 
submaxillary  and  cervical  lymph  glands. 

Adenoids  are  characterized  by  the  occurrence  of  complications 
directly  due  to  the  condition.  Among  those  most  prominently  met 
were  the  following :  Deafness  of  varying  degree  in  sixty-five  patients, 
some  complaining  of  only  slight  stuffiness  of  the  ears  and  occasional 
tennitus,  both  of  which  conditions  were  more  marked  when  the  patient 
had  a  cold.  Many  could  hear  the  whispered  voice,  if  at  all,  only  a 
fraction  of  the  normal  distance,  which  is  twenty-one  feet.  There  were 
about  thirty  patients  who  had  discharging  ears  at  the  time  of  examina- 
tion, and  many  more  cases  in  which  the  examination  showed  evidences 
of  previous  suppuration.  The  presence  of  adenoids  was  a  marked 
factor  in  the  susceptibility  to  the  acute  infectious  disease,  particularly 
measles,  scarlet  fever,  and  whooping-cough ;  repeated  attacks  of  tonsil- 
litis, pharyngitis,  and  acute  rhinitis,  the  patients  taking  cold  at  the  least 
exposure ;  a  constant  dry,  hacking  cough ;  gastrointestinal  disturbances, 
manifested  by  a  rapacious  appetite  and  alternating  constipation  and 
diarrhea;  retarded  mental  development,  many  of  the  children  being 
several  grades  less  advanced  in  school  than  normal  children  of  similar 
ages;  while  several  cases  showed  defective  development  of  the  chest, 
resulting  in  pigeon-breast. 

The  treatment  has  been  complete  removal  of  the  growth,  this  being 
done  under  primary  ether  anesthesia  with  the  patient  in  the  sitting 
position.  The  instruments  used  were  the  adenoid  forceps,  Mthen  the 
tissue  was  abundant,  followed  by  the  Beckmann  curet,  and  all  small 
portions  remaining  were  removed  with  the  finger. 

The  results  have  been  without  exception  favorable.  There  has  been 
no  case  of  hemorrhage.  Those  cases  accompanied  by  ear  complications 
have  been  very  satisfactory  both  as  to  the  improvement  in  hearing  and 
the  cessation  of  the  discharge.  The  improvement  in  the  general  con- 
dition was  very  noticable,  and  this  was  especially  true  in  the  young 
patients. 


ANN  ARBOR  MEDICAL  CLUB.  267 

Among  the  reasons  for  the  removal  of  adenoid  vegetations  may  be 
mentioned :  The  prevention  of  pathological  conditions  of  the  ears  and 
the  beneficial  effect  upon  the  ear  complications;  the  establishment  of 
free  nasal  respiration,  thus  doing  away  with  mouth-breathing  and  its 
attendant  disadvantages;  the  marked  and  rapid  improvement  in  the 
patient's  general  health.  The  last  two  conditions  were  much  more 
striking  in  the  young  patients.  The  removal  of  a  constant  source  of 
infection,  statistics  showing  that  one  case  in  five  have  tubercle  bacilli 
either  in  the  substance  of  the  growth  or  upon  its  surface,  and,  as  already 
mentioned,  the  presence  of  adenoids  increases  the  susceptibility  of  the 
patients  to  the  acute  exanthemata. 

The  dangers  of  the  operation,  if  correctly  performed,  are  very  slight 
and  the  beneficial  results  as  marked  as  those  derived  from  any  operation. 


ANN  ARBOR  MEDICAL  CLUB. 

STATED  MEETING,  APRIL  i8,  1906. 

The  President,  JOHN  A.  WESSINGER,  M.  D.,  in  the  Chair. 

Reported  by  JOHN  WILLIAM  KEATING,  M.  D.,  Secretary. 

REPORTS  OF  CASES. 

RETENTION  OF  URINE. 

Doctor  Cyrenus  G.  Darling  :  I  wish  to  report  two  cases  to  show 
some  methods  of  treating  retention  of  urine.  A  man,  seventy-five  years 
old,  had  been  using  a  catheter  for  five  years  because  of  enlarged  prostate 
and  cystitis.  One  day  he  was  unable  to  pass  the  soft  rubber  catheter 
that  he  was  accustomed  to  employ,  and  attempted  to  insert  an  old  one 
which  had  been  about  the  house  for  some  time,  because  it  was  smaller. 
The  tip  had  already  been  broken  oflF.  He  not  only  failed  in  the  attempt 
at  satisfactory  insertion  but  when  he  tried  to  withdraw  the  instrument  it 
broke,  leaving  a  piece  of  unknown  length  in  the  bladder.  To  still  further 
complicate  matters  he  threw  the  withdrawn  fragment  into  the  fire.  He 
then  called  his  physician  who  secured  three  fragments  of  catheter,  prob- 
ably all  that  had  not  been  previously  removed ;  still  the  physician  was  not 
able  to  gain  acress  to  the  bladder  because  of  the  injury  which  the  patient 
inflicted  upon  himself.  I  saw  patient  about  thirty-six  hours  later, 
when  I  found  the  bladder  enormously  distended  because  no  urine  had 
been  passed.  The  pulse  was  weak  and  he  presented  all  the  signs  of  a 
septic  condition.  I  decided  to  drain  the  bladder  but  patient  was  in  no 
condition  to  take  an  anesthetic.  I  then  made  a  suprapubic  incision 
under  local  anesthesia  (Schleich's  solution).  A  large  amount  of  very 
offensive  urine  was  allowed  to  flow  slowly  away,  and  the  patient  was 
immediately  relieved  but  was  already  so  septic  that  he  did  not  improve. 
He  became  gradually  weaker  and  died  on  the  following  day.  The  second 
case  was  that  of  a  boy  eight  years  old  who  fell  astride  of  a  stick,  com- 
pletely severing  the  urethra.  This  was  followed  by  infiltration  of  the 
perineal  tissues  and  retention  of  urine.    The  physician  failed  to  find  the 


258  ORIGINAL  ARTICLES. 

opening  of  the  torn  urethra  and  reached  the  bladder  by  puncturing  with 
a  trochar  through  the  perineuni  along  the  supposed  line  of  the  urethra, 
and  introducing  a  tube  for  the  purpose  of  forming  a  new  urethra.  After 
the  tube  was  removed  the  new  urethra  remained  for  some  weeks,  but 
gradually  contracted  until  no  urine  could  be  passed  except  by  drops. 
Patient  was  brought  to  the  University  Hospital  in  this  condition.  For 
immediate  relief  suprapubic  puncture  was  employed.  The  following 
day  I  attempted  to  find  the  end  of  the  torn  urethra  by  a  perineal  incision, 
but  failed.  I  was  obliged  to  resort  to  retrograde  catheterization  by 
incising  the  bladder,  finding  the  urethral  opening  and  introducing  a 
catheter  into  it.  This  was  carried  anteriorly  until  the  tip  could  be  felt  in 
the  perineum,  where  the  end  was  exposed  by  an  incision.  The  other 
end  was  treated  in. the  same  way.  Because  of  a  large  amount  of  cica- 
tricial tissue  no  attempt  was  made  to  suture  the  ends  but  an  English 
catheter  was  placed  in  the  canal  and  kept  there  for  a  few  days  until  the 
ends  were  approximately  united.  The  wound  in  the  bladder  was  closed. 
The  patient  left  the  hospital  with  a  good  urethra.  When  the  catheter 
fails,  retention  of  urine  may  sometimes  be  relieved  by  putting  the  patient 
in  a  warm  bath,  by  using  a  general  anesthetic  to  relax  spasm,  or  by  supra- 
pubic puncture  or  incision.  These  latter  may  frequently  be  employed 
when  a  general  anesthetic  would  not  be  safe.  Incision  should  be  made 
when  it  is  necessary  to  drain  the  bladder.  The  use  of  Schleich's  solution 
completely  anesthetizes  all  of  the  tissues  except  the  bladder  wall.  This 
is  opened  with  a  single,  rapid  incision.  Puncture  is  so  easily  and  safely 
performed  that  there  are  but  few  reasons  why  it  may  not  be  employed. 
Retention  must  always  receive  prompt  treatment  when  cystitis  is  present 
or  more  serious  ccmditions  may  follow,  as  in  the  first  case  reported. 
Retention  from  rupture  of  the  urethra  is  treated  by  early  perineal 
incision,  with  suturing  of  the  torn  ends,  or  holding  in  place  by  catheter 
as  mentioned  in  the  second  case. 

AN  UNCOMMON  FRACTURE, 

Doctor  Ira  D.  Loree:  This  fracture  is  not  uncommon  from  the 
fact  that  it  does  not  occur  frequently  but  because  it  is  not  often  diag- 
nosed. In  the  past  fracture  of  the  carpal  bones  has,  no  doubt,  many 
times  been  overlooked,  but  with  the  great  advantages  offered  by  the 
radiograph  the  true  nature  of  many  wrist  sprains  is  coming  to  light. 
This  patient  was  sent  to  me  by  Doctor  Yutzy.  His  accident  hap- 
pened while  scuffling,  which  resulted  in  a  fall  and  striking  upon  his 
hand.  Whether  or  not  he  fell  upon  it  in  a  way  to  produce  flexion  or 
extension  he  could  not  tell.  The  seat  of  injury  was  too  far  forward  to 
be  a  Colles'  fracture,  and  while  deformity  and  crepitus  were  absent, 
there  was  too  much  pain,  and  swelling  in  the  soft  parts,  not  to  interpret 
a  broken  bone.  The  radiographs  which  I  pass  around  readily  reveal 
the  seat  of  difficulty  in  the  os  magnum  and  scaphoid.  To  properly  diag- 
nose this  condition  both  wrists  should  be  photographed,  as  sesamoid 
bones  may  be  mistaken  for  fracture. 


FAT  INDIGESTION  IN  INFANTS.  259 

ORIGINAL  ABSTRACTS. 


SURGERY. 

By  FRANK  BANGHART  WALKER,  Ph.  B.,  M.  D..  Detroit.  Michigan. 
movassoK  of  sukgut  amo  opbkativb  sukgbrt  in  tub  dbtkoit  potTGKADUATS  SCHOOL  or  mboicimb: 

ADJUNCT  FftOPBSSOB  OF  OPBBATIVB  SOBGBBT  IK  THB  DBTBOIT  COC.LBCB  OF  MBOICINB. 

AND 

CYRENUS  GARRITT  DARLING,  M.  D.,  Ann  Arbor,  Michigan. 

CUMICAL  PBOFBSSOB  OF  SVKGBBT  IM  THB  UMIVBBSITT  OF  MICHIOAM. 


MORTALITY  AFTER  PROSTATECTOMY. 
In  Jcma,  Volume  XLVI,  Number  XIX,  Tenney  and  Chase  give 
some  interesting  observations  on  the  results  of  prostatectomy.  Age  of 
itself,  they  state,  is  no  argument  against  the  operation,  but  their  figures 
show  better  than  any  amount  of  argument  the  desirability  of  early  oper- 
ation. The  convalescence  of  elder  patients  was  in  marked  contrast  to 
that  of  the  younger  patients.  In  studying  seventy-three  deaths  fatal 
periods  were  noticed.  There  were  twenty-three  deaths,  or  more  fatali- 
ties in  the  first  forty-eight  hours  than  in  any  other  two  days.  Another 
period  of  mortality  includes  the  seventh,  eighth  and  ninth  days,  which 
showed  twelve  deaths.  On  the  thirteenth  and  two  following  days  there 
were  six  deaths,  and  on  the  twentieth  to  twenty-second  days  inclusive, 
there  were  seven  deaths.  Two-thirds  of  all  the  deaths  came  during 
these  fatal  periods.  Contrary  to  statements  by  MouUin,  Richardson 
and  others  that  patients  with  stone  in  the  bladder  are  more  favorable 
subjects  for  operation  than  others,  their  list  contains  one  hundred  seven 
cases  complicated  by  vesical  calculus  with  a  mortality  of  thirteen  or 
twelve  per  cent,  as  compared  with  8.6  per  cent  mortality  among  the 
cases  without  stone.  The  inferences  drawn  from  a  comparison  of  mor- 
talities with  ages  were  that  the  older  men  are  less  likely  to  stand  the 
shock  and  loss  of  blood  in  the  operation,  and  that  the  younger  men 
stand  the  sepsis,  uremic  complications  and  confinement  less  well  than 
the  elders.  Believing  that  the  result  is  not  so  much  a  problem  of  speed 
or  technic  in  the  operation,  they  lay  great  stress  upon  the  preparation 
of  the  patient,  the  anesthesia,  and  the  careful  and  intelligent  attention 
almost  constantly  during  the  first  forty-eight  hours,  and  the  same  sort 
of  attention  later  at  frequent  intervals  until  his  convelescence  is  well 
established.  f.  b.  w. 


PEDIATRICS. 

By  ARTHUR  DAVID  HOLMES,  M.  D.,C.  M.,  Detroit,  Michigan. 


FAT  INDIGESTION  IN  INFANTS. 

LowENBURG   {Medical  Bulletin,   November,    1905)    says  that  an 

excess  of  fat  may  not  infrequently  be  a  source  of  indigestion.    Infants 

thus  fed  vomit  from  half  to  an  hour  after  feeding.     The  vomited 

material  has  an  odor  of  butyric  acid  and  is  sour.    Diarrhea  is  a  frequent 


260  ORIGINAL  ABSTRACTS. 

symptom.  The  stools  are  greasy  and  respond  to  the  osmic  acid  test 
for  fat,  and  oil  globules  are  seen  with  the  microscope.  The  fat  may 
appear  in  the  stools  as  lumps  not  unlike  those  of  casein.  A  progressive 
loss  of  weight  is  soon  or  late  a  prominent  feature.  The  condition  is 
best  prevented  by  starting  the  infant  on  low  fat  percentages.  The 
increase  should  be  gradual  and  never  reach  above  four  per  cent.  In 
the  active  management  of  such  a  case  a  calomel  purge  should  be  admin- 
istered if  vomiting  is  a  permanent  feature.  The  fat  should  be  at  once 
reduced  to  less  than  one  per  cent,  and  then  only  gradually  and  carefully 
increased,  stools  and  condition  of  the  stomach  being  carefully  watched. 


TREATMENT  OF  ENURESIS. 
Thursfield  (British  Medical  Journal,  April  21,  1906)  says  that 
atropin  used  in  the  form  of  an  extract,  tincture,  or  as  liquor  atropin  is 
the  only  drug  from  which  he  has  had  good  results  in  the  treatment  of 
enuresis.  He  recommends  ten  minims  of  the  tincture  three  times  a  day 
as  an  initial  dose,  and  increases  the  amount  week  by  week  until  the 
dose  produces  evidences  of  its  action.  It  should  be  used  over  a  long 
period,  usually  from  three  to  six  months,  for  permanent  relief.  The 
dose  should  be  diminished  gradually  until  it  can  be  left  off  with  safety. 
He  also  recommends  the  use  of  potassium  citrate  in  conjunction  with 
belladonna  in  the  majority  of  cases,  and  in  some  cases  where  hyper- 
acidity of  the  urine  was  the  cause,  he  found  the  administration  of 
potassium  citrate  alone  very  efficacious.  He  also  speaks  highly  of 
urotropin  well  diluted. 

TREATMENT  OF  CEREBROSPINAL  MENINGITIS. 
Osborne  (New  York  Medical  Record,  February  17,  1906)  says, 
regarding  the  treatment  of  this  affection,  that  it  consists  in  diminishing 
the  congestion,  in  preventing  or  relieving  the  spinal  or  cerebral  pres- 
sure, and  in  combatting  the  acute  symptoms  and  complications  as  they 
arise.  He  says  further  that  the  administration  of  diphtheria  antitoxin 
in  this  affection  is  theoretically  unsound  and  practically  a  failure.  Spinal 
puncture  is  of  benefit  in  some  instances  for  the  relief  of  pressure,  but 
only  in  rare  instances,  he  believes,  is  it  indicated  for  diagnostic  pur- 
poses. The  sore  throat  should  be  treated  with  antiseptic  gargles  and 
sprays,  and  the  conjunctivitis  with  solution  of  boric  acid.  If  the  pain 
is  not  severe  and  the  pulse  good,  bromides  or  chloral  may  be  given  ; 
otherwise  treat  by  wrapping  the  painful  joints  with  cotton,  applying 
heat,  giving  a  calomel  or  saline  purge,  and  administering  morphin. 
The  author  believes  that  to  quiet  the  cerebral  excitement  and  delirium 
and  to  intensify  the  action  of  the  morphin  in  these  cases  the  adminis- 
tration of  ergot  intramuscularly  or  subcutaneously  at  six-hour  intervals 
gives  good  results.  The  ice-cap  and  the  spinal  ice-bag  are  necessary, 
and  if  the  temperature  is  subnormal  or  the  surface  of  the  body  is  cold, 
dry  hot  applications  are  of  advantage.  He  is  convinced  that  ice,  ergot, 
and  morphin  will  save  many  patients  from  death  by  this  disease. 


TUBERCULOUS  OSTEITIS  OF  KNEE. 

ORTHOPEDICS. 

ait  IRA  DEAN  LOa^  Iil^D.,  Ann  Arbor,  Michigan. 

sum  ASHITAKX  IH.  SypMSjMX  I|t.TBB  DMXTOaiTY  OV  mCMIGAM. 


261 


EARLY  OPERATIVE  TREATMENT  OF  TUBERCULOUS 
OSTEITIS  OF  THE  KNEE. 

Bernard  B/sblow,  M.  D.,  oi.  QMffalo^  in  the  American  Journal  of 
Orthopedic  Surgery  for  Aprit  19P6.  His  report.  Qonfioes,  itself  to  three 
cases  in  which  the  focus  of  disea^  had  not  reached  the  jcHnt,  but  wa3 
confined  to  the  end  of  the  femur.  He  advisee  excision  of  the  diseased 
bone,  and,  if  there  has  been  prolonged  contraction,  division  of  the 
ham-string  tendons.  ' 

The  histories  of  the  two  patieato  which  he  presents  a^re  to  substan- 
tiate his  previously  reported  resulte.  in  this  tine  o{  workv 

The  first  patient  was  a  girl,  niw  years  old,  with  flexion  posture  of 
forty-five  degrees  and  a  range  of  free  movement  of  fifteen  degrees. 
There  was. much  enlargement  of  th^ inner  condyle  (Figure  I)  with  pajja 
at  this  point  upon  digital  pressure.    The  tibia  wa^  partially  subluxated 


First  Patient — Figure  I. 


First  Patient— Figure  II. 


with  abduction  and  some  rotation  outward.  She  had  passed  the  stage 
of  muscular  spasm  and  night  cry.  After  thoroughly  cleaning  out  the 
area  of  disease  the  cavity  was  swabbed  with  a  five-per-cent  formalin 
solution,  aft^r  which  the  periosteum  and  skin  were  repaired.  A  plaster- 
of- Paris  splint  was  applied  as  shown  (Figure  II).  After  four  weeks 
the  condition  present  was  as  indicated  in  Figure  III.  Figure  IV  shows 
the  amount  of  flexion  obtained  after  twelve  months.     Genu  valgum 


1 


262 


ORIGINAL  ABSTRACTS. 


First  Patient — Figure  III. 


First  Patient — Figure  IV. 


First  Patient -Figure  V. 


First  Patient — Figure  VI. 


TUBERCULOUS  OSTEITIS  OF  KNEE. 


263 


developed  later  as  shown  in  Figure  V.  There  was  no  return  of  the 
tubercular  process,  however,  and  the  former  condition  was  corrected  by 
osteotomy,  with  results  shown  in  Figure  VI. 

The  second  patient  was  a  boy,  three  years  of  age.     Disease  had 


Second  Patient— Figure  VII.  Second  Patient— Figure  VIII. 

progressed  for  three  months  when  first  seen.  The  joint  had  a  typical 
posture  with  its  enlarged  inner  condyle,  night  cry  and  pain  through  the 
day,  with  morning  lameness.  There  was  flexion  posture  of  twenty 
degrees  with  very  slight  free  movement.    Treatment  was  the  same  as 


Second  Patient — Figure  IX. 
before.     It  was  necessary  here  to  penetrate  healthy  epiphyseal  tissue. 
Massage  and  passive  motion  were  employed  after  the  sixth  week. 
Figures  II  and  III  show  the  joint  eleven  months  after  the  operation 
with  posture,  growth  and  range  of  motion  normal. 


864  ORIGINAL  ABSTRACTS. 

OPHTHALMOLOGY. 

'      By  WALTER  ROBERT  PARKER,  B.  S.,  M.  O. 
rmowwMom  ov  onrrHAUiouwv  m  tub  uwnMinr  of  michioam. 


EXPERIMENTAL  INVESTIGATIONS  ON  THE  INFECTION 
OF  CORNEAL  WOUNDS  BY  SALIVA. 

HocTA  (Kim.  MonaisbL  fur  AugenkmOhmde,  September,  1905) 
has  ftnmd  that  saliva  may  be  brought  iit  omtact  with  corneail  wounds 
by  means  of  objects  contaminated  with  saliva,  sudt  as  fiigers.  and 
handcercbiefs,  or  drops  of  saliva  may  come  fhim  the  iterator's  miMUli. 

The  writer's  experiments  were  partly  to  determine  (a)  what  organ- 
isms in  the  saliva,  when  in  contact  with  a^  newly-made  corneal  wound, 
are  most  likely  to  produce  a  purulent  ker^itis,  and  (b)  what  forait  of 
wound,  exposed  to  the  microorganisms  of  the  saliva,  is  most  likely  to 
give  rise  to  purulent  inflammation. 

For  his  experiments  rabbits,  cats,  and  mice  were  used.  Saliva  was 
obtsuned  from  persons  of  different  ages  and  positions.  The  lids  were 
everted  and  the  eye  washed  with  0.05  per  cent  sublimate  lotion,  then 
witii  physiologic  saline  solution. 

A  wound  was  made  in  the  cornea : 

(aa)  Nonperf orating. 

(i)  An  abrasion  by  scratching  the  surface  of  the  cornea  with 

the  point  of  a  needle. 
(2)  A  pocket,  a  wound  made  by  a  keratome  between  the  corneal 
lamellae. 

(bb)  Perforating  wounds  made  by  a  Graefe  knife. 

Saliva  taken  from  a  sterile  Petrie  dish,  by  means  of  a  sterilized 
spatula,  was  carefully  rubbed  on  the  wound,  or  inserted  into  the  pocket. 
In  the  case  of  perforating  wounds  care  was  taken  not  to  introduce  the 
spatula  into  the  anterior  chamber. 

After  twenty-four  hours  a  cover-glass  preparation  and  a  culture 
were  made  from  the  secretion  of  the  wound.  The  media  used  were 
neutral  agar,  glycerine  agar,  Loeffler's  blood  serum,  and  bouillon.  All 
media  were  placed  in  an  oven  at  35°  centigrade. 

Results  of  ninety  experiments : 

(a)  Always  negative  in  thirty  perforating  wounds. 

(b)  Once  positive  in  diirty  abrasions. 

(c)  Always  positive  in  thirty  pocket  wounds.  In  most  of  these 
cases  there  was  iritis,  hypopyon,  marked  circumcomeal  injection  and 
conjunctivitis. 

In  these  thirty  cases  pneumococci  were  found  eleven  times  (thirty-six 
per  cent)  ;  streptococci  seventeen  times  (fifty-six  per  cent)  ;  staphy- 
lococci nine  times  (thirty  per  cent) ;  tetragenus  was  also  seen  five  times. 
In  six  of  the  cases  no  culture  was  obtained. 


CANCER  OF  THE  LARYNX.  966 

Infectioii  of  operation  wounds  by  drops  of  saliva  from  the  operator : 
Hotta  performed  experiments  similar  to  those  of  Hubener,  but  modi- 
fied them  in  view  of  the  special  conditions  present  in  eye  operations. 
He  found  that  a  veil  of  doubled  muslin  does  not  absolutely  prevent  the 
spraying  of  the  saliva.  But  he  believes  that  in  eye  operations  this  is 
certainly  sufficient  to  prevent  infection  from  the  mouth.  The  possi- 
bility of  infection  from  the  saliva  during  the  operation  cannot  be  abso- 
lutely denied,  yet.it  must  be  so  rare  that  in  eye  operations  in  general 
a  special  measure  to  prevent  it  does  not  seem  necessary. 


LARYNGOLOGY. 

By  WILLIS  SIDNEY  ANDERSON,  M.  D.,  Detroit,  Michigan. 

ASSISTANT  TO  THB  CMAIE  ^F  LABYNOOLOOT  IN  THB  DBTROIT  COLLBOB  OF  MBDICINB. 


REMARKS  ON  THE  MACROSCOPIC  DIAGNOSIS  AND  GEN- 
ERAL INDICATIONS  FOR  TREATMENT  OF 
CANCER  OF  THE  LARYNX. 

Doctor  John  Noland  Mackenzie  (Annals  of  Otology,  Rhinology 
and  Laryngology,  March,  1906)  makes  some  positive  statements  in 
regard  to  this  much  dreaded  disease.  He  states  that  in  the  present 
state  of  our  knowledge  there  are  three  principal  methods  of  diagnosis 
in  laryngeal  cancer : 

(i)  The  naked  eye  method,  or  diagnosis  by  direct  inspection,  sup- 
plemented by  clinical  phenomena. 

(2)  Thyrotomy. 

(3)  The  microscope. 

Take  it  all  in  all,  the  first  method  is  the  most  practicable  and  satis- 
factory of  the  three.  The  author  insists  very  strongly  on  the  applica- 
tion of  the  naked  eye  method  of  diagnosis  in  the  case  of  malignant 
tumors  of  the  larynx.  Every  recourse  and  refinement  of  clinical  diag- 
nosis, including  the  exclusion  of  S3rphilis  by  the  iodides,  and  tubercu^ 
losis  by  tuberculin,  should  be  resorted  to  before  appeal  to  the  micro- 
scope is  made.  By  following  the  lead  of  the  general  surgeon,  with  the 
means  of  clinical  diagnosis  at  our  command,  together  with  the  more 
exact  information  concerning  the  naked  eye  appearances  of  the  cut 
surface  of  laryngeal  neoplasms,  we  will  soon  be  in  a  position  where  we 
will  be  more  and  more  independent  of  the  pure  pathologist  for  help  in 
diagnosis. 

The  objections  urged  against  the  indiscriminate  removal  of  tissue 
for  examination,  especially  when  done  through  the  natural  passages, 
are  as  follows : 

(i)  It  subjects  the  patient  to  the  danger  of  autoinfection  at  the 
point  of  incision  and  to  metastasis  elsewhere. 

(2)  It  stimulates  the  local  growth  of  the  cancer. 


266  ORIGINAL  ABSTRACTS. 

(3)  Finally,  the  method  is  often  inconclusive,  misleading,  and  some- 
times practically  impossible. 

In  practically  all  cases  of  laryngeal  cancer,  death  is  due  to  metas* 
tasis.  In  neighboring  organs  (the  neck  and  mouth)  metastasis  takes 
place  with  certainty  and  at  an  early  date.  It  is,  therefore,  probable 
that  the  glands  of  the  neck  are  affected  in  cancer  of  the  larynx,  although 
perhaps  not  recognizable  by  the  senses  of  sight  and  touch,  at  a  much 
earlier  period  than  is  generally  supposed.  It  is  at  all  events  safer  to 
assume  this  to  be  the  fact  than  to  accept  the  statement,  unsupported  by 
definite  anatomical  proof,  that  cancer  in  the  interior  of  the  larynx 
remains  for  a  more  or  less  indefinite  period  as  a  purely  localized  disease, 
and  does  not  get  into  the  lympathics  of  the  neck  until  a  late  stage  of  the 
affection. 

The  author  is  very  much  opposed  to  intralaryngeal  operation,  and, 
in  a  general  way,  is  pessimistic  in  regard  to  the  permanent  cure  by 
surgical  measures,  although  advocating  the  thorough  removal  of  the 
growth  if  seen  in  the  earlier  stages. 


PROCTOLOGY. 

By  LOUIS  JACOB  HIRSCHMAN,  M.  D.,  Detroit,  Michigan. 

CUNICAL  PROFUaOB  OV  PROCTOtjOGT  IM  TUB  DBTmOlT  COLLSCB  OV  BCBDICXMB. 


LOCAL  AND  REGIONAL  ANESTHESIA  IN  RECTAL 

SURGERY. 

Cooke  (Janta,  Volume  XLVI,  Number  XXII)  states  that  in  the 
last  twenty  months  he  has  employed  local  anesthesia  in  seventy  cases  of 
rectal  and  anal  surgery  comprising  thirty-eight  cases  of  internal  hemor- 
rhoids, two  of  prolapsus  ani,  five  of  fistula,  nine  of  fissure,  and  sixteen 
of  external  hemorrhoids. 

Pressure  anesthesia  by  means  of  injections  of  sterile  water  or  weak 
solutions  of  anesthetic  drugs,  was  employed  in  all  cases.  For  fissure 
and  external  hemorrhoids,  0.25  to  0.5  per  cent  beta-eucain  solutions 
were  used  to  anesthetize  the  integument  in  preference  to  sterile  water 
anesthesia.  From  personal  experience  Cooke  feels  warranted  in  claim- 
ing for  local  anesthesia  in  rectal  surgery,  the  following  advantages : 

( 1 )  It  is  simple,  safe  and  effective. 

(2)  It  eliminates  the  dangers  and  discomforts  of  general  anesthesia. 

(3)  Pain  at  the  time  of  operation  is  usually  absent  and  always  so 
slight  as  to  be  easily  borne. 

(4)  Postoperative  pain  is  less  by  far  than  after  the  old  methods. 

(5)  Time  required  for  the  operation  is  greatly  reduced. 

(6)  Confinement  to  bed  is  rendered  a  matter  of  expedience,  rather 
than  necessity. 

(7)  The  period  of  detention  from  business  is  diminished  fully  one- 
half. 


MERALGIA  PARESTHETICA.  267 

(8)  Under  this  method  the  hospital  becomes  a  convenience  and 
luxury  rather  than  a  dreaded  essential. 

(9)  It  is  a  thoroughly  reliable  means  of  affording  relief  in  many 
cases  which  would  otherwise  be  unsuitable  for  operation. 

( 10)  It  robs  these  operations  of  their  terrors  and  makes  it  possible 
to  reclaim  this  work  from  the  hands  of  the  "no  knife"  advertisers. 


DERMATOLOGY. 

By  WILLIAM  FLEMING  BREAKEV.  M.  D.,  Ann  Arbor,  Michigan. 

CUmCAL  FItOPnSOB  OP  DBKMATOLOGT  AlffD  STFMILOLOGT  IK  THE  UmVnSITT  OT  MICHIGAN. 

AND 

JAMES  FLEMING  BREAKEY,  M.  D.,  Ann  Arbor,  Michigan. 

ASSISTANT  IN  DBKICATOLOGT  IN  TMB  UNIVBHSTTV  OF  MICHIGAN. 


"A  NOTE  ON  THE  TREATMENT  OF  SIMPLE  WARTS  BY 
INTERNAL  REMEDIES,"       , 

Under  this  titk  Arthur  Hall  refers  (British  Journal  of  Dermatol- 
ogy, March,  1906)  to  a  case  previously  reported  by  him  in  which 
numerous  warts  of  the  scalp,  of  two  years  duration,  disappeared  in  two 
to  three  weeks'  time  under  the  administration  of  mistura  alba  thrice  daily. 
Doctor  Chalmers  Watson  had  claimed  that  it  was  not  the  drug  but 
the  purgation  which  accomplished  the  result,  and  Hall  now  reports  a 
case  seeming  to  bear  out  that  theory. 

A  girl,  age  fourteen,  came  to  his  clinic  almost  incapacitated  by 
reason  of  warts  on  wrists,  hands,  and  fingers,  she  having  counted  three 
hundred  sixty-seven  on  one  hand  and  wrist  alone.  She  had  always 
been  constitpated.  Mistura  alba  (one-half  ounce  three  times  a  day) 
was  prescribed  and  used  five  days.  The  bowels  still  being  costive  the 
dose  was  doubled  with  still  no  improvement.  After  two  weeks  without 
change  confection  sulphur  and  confection  senna  (one  dram  of  each) 
was  substituted  without  result.  Eleven  days  later  the  sulphur  was 
discontinued  and  an  aloin  and  nux  pill  prescribed.  Within  a  week 
following  this  the  warts  began  to  shrink.  The  bowels  were  regular. 
The  treatment  was  continued  for  about  two  and  one-half  months, 
at  which  time  the  hands  and  wrists  were  clean  and  but  slight  evidences . 
of  the  warts  remained  on  the  fingers.  This  without  the  use  of  any 
local  treatment.  j.  f.  b. 

MERALGIA  PARESTHETICA. 

Doctor  James  C.  White  reports  (Journal  of  Cutaneous  Diseases, 
April,  1906)  the  following  case  as  of  especial  interest  in  view  of  the 
fact  that  he  has  been  unable  to  find  the  affection  mentioned  in  any  sys- 
tematic work  on  dermatology  or  its  symptomatology  referred  to  in 
chapters  devoted  to  disturbances  of  sensation. 

The  patient,  a  male,  age  fifty-five  years,  became  aware  of  disturbed 


268  ORIGINAL  ABSTRACTS. 

sensations  in  the  skin  of  the  outer  lower  two-thirds  of  the  ri^^t  thigh 
after  his  customary  walk  of  four  or  five  miles.  The  sensation  was  of 
a  tingling  nature.  From  this  time  on— either  standing  or  walking — 
this  region  became  the  seat  of  a  variety  of  perverted  sensations, 
tingling)  tenseness,  tearing,  and  sometimes  a  dull,  deep  ache.  These 
sensations  were  often  usherd  in  by  a  growing  sensaticxi  in  the  part 
The  disturbances  usually  ceased  on  sitting  or  lying  but  might  recur  in 
these  attitudes  from  overstretching  or  twisting  the  leg.  Deep  pressure 
over  the  area  might  also  bring  on  the  sensations.  There  was  always 
a  sensation  of  something  wrong  on  standing  or  walking.  No  pruritus 
or  throbbing  or  feeling  of  constriction  was  noticed.  The  area  com- 
plained of  corresponded  to  the  distribution  of  the  cutaneous  filaments 
of  the  external  cutaneous  femoral. 

Inspection  of  the  leg  showed  little  difference  from  its  fellow,  perhaps 
a  little  paler.  Induced  hyperemia  recedes  more  slowly  than  in  its 
fellow.  The  whole  area  was  partially  anesthetized,  and  over  the  patella 
anesthesia  was  complete.  Deep  pressure  over  both  legs  showed  little 
difference  in  sensation.  Dimensions  of  legs  the  same.  Habits  of 
patient  good. 

Meralgia  paresthetica  is  a  condition  always  confined  to  the  area 
occupied  in  this  case.  It  was  first  described  about  ten  years  ago  by 
Ben^ardt  and  Roth,  and  is  described  in  works  on  nervous  affections, 
but  Doctor  White  presents  it  as  having  claims  for  recognition  in  the 
lists  of  cutaneous  diseases.  The  neurologists  have  offered  little  that  is 
definite  as  to  its  cause. 

Treatment  is  unsatisfactory,  though  massage  gave  partial  and 
temporary  relief. 

It  has  no  apparent  effect  upon  the  general  welfare  of  the  patient. 

J.  F.  B. 


NEUROLOGY. 

By  DAVID  INGLIS,  M.  D.,  Detroit,  Michigan. 
PROvnaoK  or  mmvoos  amo  icbmtal  disbaski  ik  tmb  dbtkoit  coixacs  or  icBDicim. 

AND 

IRWIN  HOFFMAN  NEFF,  M.  D.,  Pontiac,  Michigan. 

ASSISTANT  PMnXCIAN  AT  TMB  BASTBBK  MICMIOAK  ASTLUM. 


"TYPES  IN  MENTAL  DISEASES." 

William  A.  White  has  an  article  in  the  Journal  of  Nervous  and 
Mental  Disease  (April,  1906)  on  this  subject.  The  author  gives  a 
rather  cursory  review  of  the  insanities,  following  Kraeplin's  grouping 
of  the  psychoses.  He  emphasizes  the  difficulty  of  differentiating  some 
of  these  types,  and  calls  particular  attention  to  the  transitional  forms, 
deprecating  the  custcxn  of  analyzing  mental  diseases  with  a  primary 
tendency  to  group  the  mental  trouble.  He  believes  that  this  method  of 
attempting  to  g^oup  the  psychoses  before  a  complete  analysis  of  the 
syndrome  may  lead  to  confusion.     White  gives  a  table,  dividing  the 


AMERICAN  MEDICAL  ASSOCIATION  MEETING.  209 

psychoses  into  two  great  groups— dementing  and  nondementing 
psychoses.  These,  with  necessary  subdivisions,  form,  as  he  believes, 
a  practical  working  classification.  In  conclusion  he  makes  the  following 
summary: 

(i)  The  necessity  for  a  broad  biological  viewpoint  in  considering 
the  problems  of  mental  alienation. 

(2)  The  inconstancy  and  variability  of  t3rpes  in  mental  disease  as 
shown  by  , 

(a)  The  occurrence  of  transition  and  intermediate  forms. 

(b)  The  overlapping  of  superposition  of  clinical  types. 

(c)  The  occurrence  of  special  groups  of  symptoms — syndrcmies 

— ^in  widely  different  clinical  pictures. 

(3)  The  desirability  of  a  pause  in  the  universal  tendency  to  the 
analysis  of  mental  symptoms  for  the  purpose  of  developing  general 
principles  under  which  to  group  results. 

(4)  The  suggestion  that  a  great  deal  could  be  accomplished  in  this 
direction  by  the  study  of  certain  symptom  groups  apart  from  the  special 
diseases  which  they  more  or  less  typify. 

(5)  The  illustratk)n  of  what  can  be  accomplished  by  this  method  by 
its  application  to  the  dementia  syndrome.  i.  h.  n. 


EDITORIAL  COMMENT. 


AMERICAN  MEDICAL  ASSOCIATION  MEETING. 

Boston  is  entitled  to  the  glory  of  being  the  scene  of  the  banner  meet 
of  the  American  Medical  Association,  the  unprecedented  attendance  of 
over  five  thousand  having  been  registered  at  the  recent  gathering  of 
the  clans  in  that  city.  Whether  the  national  event  was  the  sole  magnet 
that  attracted  this  multitude,  or  whether  the  practically  coincident  annual 
meeting  of  the  Massachusetts  Medical  Society,  which  contributed  about 
one-fifth  of  the  number,  was  the  potential  factor  in  effecting  high-water 
mark  on  this  occasion  is  immaterial  insofar  as  concerns  yielding  the 
palm  to  Boston  for  the  greatest  display  of  lapel  insignia  medical  since 
the  inception  of  the  national  body.  From  the  viewpoint  of  both  scientific 
and  business  achievement  the  meeting  was  likewise  a  memorable  event, 
but  since  the  organization  seems  to  be  developing  a  commercial  spirit 
which  bids  fair  to  completely  overshadow  the  intent  of  its  original 
promoters,  the  business  aspects  will  be  accorded  preference  in  reviewing 
some  of  the  more  important  questions  that  received  consideration. 

4t       4t       4k 

Doctor  McMurtry,  in  his  address  before  the  House  of  Delegates, 
congratulated  the  association  on  the  removal  of  every  vestige  of  the  old 
disagreements  between  New  York  medical  men  and  the  return  of  the 
profession  of  that  state  as  a  united  body.    Attention  was  directed  to  the 


270  EDITORIAL  COMMENT. 

dissatisfaction  that  prevails  regarding  the  action  of  the  Council  of 
Pharmacy  and  Chemistry  in  excluding  advertisements  of  certain  pro- 
prietary medicines  from  the  journal  conducted  by  the  association,  the 
contention  having  aroused  a  marked  degree  of  antagonism  toward  the 
supposed  policy  of  the  secretary-editor  who  was  merely  executing  the 
mandates  of  the  trustees.  Indeed  dissatisfaction  with  the  management 
of  the  association  generally  has  assumed  such  proportions  that  a  resolu- 
tion was  introduced  requesting  the  appointment  of  a  committee  to  inves- 
tigate the  affairs  of  the  secretary  and  treasurer,  but  the  shortsightedness 
of  zealous  friends  was  responsible  for  tabling  the  measure  and  thereby 
unfortunately  committing  the  officers  to  unwarranted  suspicion.  If  The 
report  of  Doctor  Simmons  disclosed  the  informaticm  that  there  were 
23*636  members  in  the  association,  4,351  having  affiliated  therewith 
during  the  past  year.  ^  Doctor  Happell,  chairman  of  the  Board  of  Trus- 
tees, reported  that  the  association  was  in  a  flourishing  condition  finan- 
cially, the  assets  being  nearly  $238,000.  During  the  past  year  the  income 
from  all  sources  aggregated  about  $275,000.  The  expenses  for  this  period 
were  approximately  $250,000,  leaving  an  annual  income  of  $25,000  to 
augment  the  total  net  assets  to  $247,500.  With  an  indebtedness  of  only 
about  $10,000  the  above  rendering  certainly  justifies  continuance  of  the 
incumbent  financial  management,  f  Doctor  Reed,  of  the  Committee  on 
Medical  Legislation,  reported  the  recommendation  of  an  appropriation 
to  facilitate  the  formulation  of  a  bill  for  the  department  of  public  health 
and  the  payment  of  current  expenses  of  the  Committee.  If  Doctor 
Rodman,  of  Philadelphia,  called  attention  to  the  necessity  for  uniform- 
ity of  license  g^nting  in  the  various  commonwealths  of  the  United 
States,  and  while  deploring  the  improbability  of  inunediate  naticmal 
control  of  licensiation,  suggested  that  the  Council  on  Medical  Education 
should  be  empowered  to  issue  licenses  to  practice  medicine  in  any  state. 
If  The  report  of  Doctor  Keen,  chairman  of  the  Committee  on  the  Walter 
Reed  Monument  Fund,  showed  that  $19,700  was  m  hand  and  $1,200  in 
subscriptions  outstanding.  The  ungratefulness  of  human  nature  is 
manifest  in  the  fact  that  quarters  rendered  immune  to  yellow  fever  by 
the  discovery  of  Doctor  Reed  ccmtributed  the  smallest  amounts  to  his 
memory.  If  A  series  of  resolutions  endorsed  the  conduct  of  Secretary 
Simmons  and  disclaimed  any  intention  on  the  part  of  the  American  Med- 
ical Association  or  the  State  Medical  Societies  to  injure  the  independent 
medical  journals  owned  or  edited  by  physicians — ^the  later  declaration 
precipitating  in  face  of  the  fact  that  the  independent  medical  journals 
are  confronted  by  a  system  of  competition  which  frequently  proffers 
advertising  space  for  a  pittance  and  invariably  renders  puUication 
without  price.  However,  this  is  considered  legitimate  privilege  in 
business  transaction.  It  is  likewise  considered  legitimate  criterion  in 
judging  valuation. 

*       4:       4t 

The  literary  program  contained  many  papers  that  afforded  excellent 
food  for  thought  and  action.    Doctor  Mayo,  in  his  presidential  address. 


AMERICAN  MEDICAL  ASSOCIATION  MEETING.  271 

discussed  "The  Medical  Professicm  and  the  Issues  which  Confront  It," 
considering  the  profession  and  the  public ;  public  health  legislation ;  med- 
ical education,  state  licensure,  and  reciprocity;  relations  to  insurance 
companies,  corporations,  et  cetera ;  the  practice  of  medicine  as  a  business ; 
and  concluded  with  a  peroration  on  medical  progress,  from  which  this 
beautiful  passage  is  reproduced :  "What  are  the  rewards  of  so  laborious 
a  life?  They  cannot  be  measured,  because  there  is  no  standard  of  com- 
parison. To  realize  that  one  has  devoted  himself  to  the  most  holy  of  all 
callings,  that  without  thought  of  reward  he  has  alleviated*  the  sufferings 
of  the  sick  and  added  to  the  length  and  usefulness  of  human  life,  is  a 
source  of  satisfaction  that  money  cannot  buy.  I  know  many  a  man 
grown  gray  in  the  profession  with  little  of  a  tangible  nature  to  show  as  a 
result  of  his  work,  but  who  is  not  only  contented  with  his  lot,  but  proud 
to  have  served  in  the  ranks,  and  who  looks  back  on  a  life  of  privation  and 
hardship  for  the  benefit  of  humanity  as  a  privilege  which  he  is  thankful 
has  been  vouchsafed  him."  ^  Among  the  various  contributions  to  the 
sections  were  several  which  discussed'  the  conduct  and  practices  of 
physicians  themselves.  Doctor  Jacobi,  of  New  York,  read  a  paper  on 
"Quackery,"  in  which  he  declared  that  physicians  were  responsible  in 
great  degree  for  the  self-dosing  with  patent  medicines.  Many  doctors 
prescribe  nostrums  and  support  medical  journals  that  publish  "reading 
notices,"  that  publish  advertisements  of  drugs  in  the  guise  of  "original 
articles,"  and  that  alternate  medical  with  advertising  pages.  If  Doctor 
Dock,  of  Michigan,  discussed  "Proprietary  Medicines  and  Their 
Abuses."  The  exclusion  of  advertising  laudatory  of  these  products 
would  not  be  likely  to  elevate  the  morals  of  physicians  already  employ- 
ing them  in  practice.  The  most  efficacious  proprietary  medicaments 
would  continue  to  be  manufactured  and  advertised,  but  crude  exper- 
imentation could  be  discouraged  by  treating  the  advent  of  new  drugs 
as  lightly  as  one  would  treat  a  new  phase  of  mental  healing  or  a  new 
application  of  massage.  The  abuse  of  proprietary  medicines  sprang 
partly  from  the  exaggeration  of  legitimate  commercial  methods,  and 
partly  frcMn  the  credulity  of  the  medical  profession.  It  is  within  the 
province  of  the  profession  to  determine  the  virtue  and  vogue  of  every 
medicinal  product  recommended  for  the  treatment  of  disease.  IfAt  a 
meeting  of  medical  editors,  Doctor  Pilcher,  of  Pennsylvania,  contrib- 
uted a  paper  in  which  medical  editors  were  classified  and  defined,  a 
summary  of  opinion  being  embraced  in  the  following:  "We  conclude, 
then,  (i)  that  while  medical  journalism  as  a  prop  to  practice  and  a 
bridge  over  the  impecuniosity  of  early  professional  years  may  be  of  some 
advantage  to  the  profession  as  well  as  to  the  temporary  editor ;  (2)  that 
while  medical  journalism  for  the  purpose  of  developing  special  lines  of 
•  professional  and  mercantile  work  may  be  of  much  service  to  many  of  the 
profession ;  (3)  that  while  there  are  a  small  number  of  men  who  possess 
the  exceptional  executive  and  literary  ability  necessary  to  conduct  pro- 
fessional and  editorial  work  at  the  same  time — ^the  medical  journalism 
of  the  twentieth  century  increasingly  demands  the  whole  intellectual  and 


272  EDITORIAL  COMMENT. 

physical  energy  of  its  editorial  conductors  in  the  presence  of  the  great 
aggregation  of  professional  atoms  which  is  daily  falling  upon  the  profes- 
sional field  to  be  excavated  and  investigated,  and  the  during  away  of 
which,  for  the  benefit  of  the  twentieth  century  practitioner,  will  demand 
the  entire  absorption  of  the  mind,  soul,  and  body  of  the  conscientious 
medical  editor  who  really  desires  to  be  a  helper  to  the  profession  and  a 
leader  in  the  medical  work  of  the  age." 


ANNOTATIONS. 


THE  INFLUENCE  OF  MINERAL  WATER  ON  MICROBES. 

Rheinbolt,  in  a  German  publication,  describes  his  experiments  on 
the  bacillus  prodigiosus  with  radioactive  mineral  water.  That  minerals 
of  all  kinds  exert  a  deteriorating  influence  <mi  bacteria  is  a  well-known 
fact,  and  that  mineral  water  is  also  an  inhibitant  to  bacterial  growth  was 
disclosed  by  the  experiments  of  this  scientist.  While  old  water,  bottled 
for  commercial  purposes,  seemed  to  have  lost  its  attenuating  power, 
fresh  specimens,  taken  from  the  spring,  destroyed  the  organisms  in  a 
boullion  culture  after  a  contact  of  four  hours,  the  activity  of  the  water, 
however,  decreasing  after  this  time.  Efforts  to  recharge  the  liquid  with 
radium  emanations  proved  to  a  degree  futile,  and  this  fact  is  responsible 
for  the  conclusion  that  mineral  water  possesses  inhibitory  properties 
other  than  are  represented  in  this  metal. 


INVESTIGATIONS  BEARING  ON  ANIMAL  INTELLIGENCE. 

The  study  of  animals,  the  degree  of  their  intelligence,  the  acuteness 
of  their  vision,  and  the  capacity  of  their  comprehensicMi  is  indeed  interest- 
ing. However,  owing  to  our  inability  to  decipher  their  vernacular,  or 
whatever  phonetic  means  of  communication  they  may  possess,  we  are 
unable  to  successfully  penetrate  their  mentality.  Zell  has  studied  the 
subject  quite  comprehensively,  and  in  a  contribution  to  a  German  publi- 
cation details  his  observations.  That  monkeys  are  equipped  with  a  keen 
sense  of  sight  he  is  convinced,  and  that  their  power  of  discrimination  is 
above  the  ordinary  he  determined  when  studying  the  quadrumana  in  the 
Berlin  Zoological  Garden.  Contrary  to  the  usual  spirit  of  audacity  which 
characterizes  these  animals,  one  of  them  utterly  ignored  the  visitors  and 
concentrated  her  attention  on  a  street  vehicle,  seemingly  wrapped  in  deep 
thought.  On  asking  the  keeper  the  cause  of  her  concern  the  observer 
was  informed  that  instead  of  the  customary  horse  the  conveyance  was 
attached  on  this  occasion  to  a  donkey,  and  the  aural  appendages  and 
other  equine  dissimilarities  had  incited  her  curiosity.  Monkeys  are 
equipped  with  a  comparatively  poor  olfactory  apparatus,  and  must 
depend  almost  entirely  upon  their  sense  of  sight  to  warn  them  of  the 


PHYSICIANS  AND  PHILOSOPHERS.  273 

approach  of  animals  of  prey  and  other  malefactors.  Dogs,  on  the  other 
hand,  so  far  as  scientists  have  been  able  to  determine,  have  an  excellent 
sense  of  smell,  but  of  the  power  of  their  optical  adjustment  little  is 
known.  Deer  and  roebuck  have  comparatively  poor  eyes  but  excellent 
noses.  Observation  has  taught  that  animals  are  more  vindictive  to 
enemies  than  is  man,  and  in  consequence  of  the  constant  vigil  which 
beasts  of  the  jungle  must  maintain  on  account  of  the  murderous  assaults 
of  preying  foes,  nature  has  wisely  endowed  them  either  with  keen  percep- 
tion or  acute  sense  of  smell. 


STOICISM  OF  EARTHQUAKE  SUFFERERS. 

The  stoicism  with  which  Californians  view  the  calamity  to  the  city 
of  San  Francisco  is  displayed  in  an  article  which  lately  appeared  in  a 
western  publication.  In  comparing  the  deaths  resultant  from  the  earth- 
quake to  those  sustained  in  recent  American  catastrophes  the  utmost 
optimism  is  exhibited.  In  the  Iroquois  theater  conflagration  in  Chicago 
more  than  five  hundred  persons  met  death,  and  over  one  thousand  lives 
were  sacrificed  in  the  burning  of  the  steamer  "Slocimi"  in  New  York 
harbor.  Thus  it  will  be  seen  that  sinc^e  only  three  hundred  thirty-three 
persons  succumbed  from  fire  and  quake  in  the  California  metropolis,  the 
loss,  while  appalling,  is  c<Mnparatively  small.  The  author  argues  that 
within  the  course  of  a  few  weeks  more  than  three  hundred  persons  would 
have  died  from  natural  causes,  and  inasmuch  as  hundreds  of  births  will 
occur  in  San  Francisco  within  a  year,  the  depopulating  effect  of  the  dis- 
aster is  not  so  severe  as  would  at  first  be  imagined.  Indeed,  when  con- 
trasted with  other  catastrophes,  the  death  list  is  insignificant. 


CONTEMPORARY. 


PHYSICIANS  AND  PHILOSOPHERS. 

[pmoraaaoK  chaklbs  william  supkr,  ov  omio  vnivbrsitt,  in  populak  scibmck  monthly.] 
{C»niinu4d  from  ^ag»  2t3b.) 

According  to  Homer  and  Herodotus,  the  healing  art  was  discovered 
or  invented  in  Egypt.  The  Odyssey  tells  us  that  there  every  man  is 
a  physician  skilled  beyond  human  kind.  Mention  is  also  made  of  the 
many  plants  possessing  medicinal  properties.  Oculists  are  said  to 
have  been  particularly  numerous,  and  many  prescriptions  for  diseases 
of  the  eye  have  been  found  among  the  papyri.  Artificial  and  gold- 
filled  teeth  have  also  been  met  with  both  in  Egypt  and  in  Etrurian 
tcrnibs.  The  practise  of  medicine  was,  however,  purely  empirical,  and 
the  rules  followed  in  the  treatment  of  particular  diseases  were  often 
of  great  age.  The  second  king  of  Egypt  is  said  to  have  been  a  physi- 
cian, and  another  is  reported  to  have  written  a  book  on  anatomy.  The 
private  physicians  of  both  Cambyses  and  of  Darius  were  Egyptians. 


274  EDITORIAL  COMMENT. 

The  name  of  the  latter  brings  to  mind  that  of  his  son  Artaxerxes  whose 
private  physician  was  a  man  of  considerable  importance  in  his  day, 
outside  of  his  profession.  Ktesias  was  a  native  of  Knidos,  a  contem- 
porary of  Hippocrates,  and  no  doubt  personally  known  to  him.  Here 
we  have  again  the  philosopher  and  the  physician  in  the  same  person. 
After  acquiring  considerable  reputation  in  his  own  country  he  had  the 
misfortune  to  fall  into  the  hands  of  the  Persians.  Subsequently  he 
was  introduced  at  court,  which  proved  the  beginning  of  his  good 
fortune.  After  the  battle  of  Cunaxa  he  healed  the  wound  inflicted  upon 
his  master  by  the  brother  of  the  latter.  Later  he  was  employed  on  a 
diplomatic  mission  to  his  native  land;  and  thus  after  an  absence  of 
seventeen  years  returned  home  about  398  B.  C,  to  remain  for  the  rest  of 
his  life.  That  he  was  well  treated  by  the  master  whose  slave  he  became, 
according  to  Persian  parlance,  and  had  abundant  opportunities  for 
study,  is  evident  from  the  fact  that  he  compiled  a  'History  of  Persia,' 
a  work  in  which  he  charged  Herodotus  with  frequent  falsehoods  in 
what  he  relates  about  that  country.  His  scholarly  tastes  are  evinced 
by  this  extensive  collection,  as  it  must  have  been,  since  it  was  divided 
into  twenty-three  books.  He  also  composed  a  small  work  on  India 
and  one  on  geography.  He  is  not  known  to  have  left  any  medical 
writings,  and  his  reputation  for  impartiality  as  a  historian  is  not  very 
good.  Still  it  must  be  regarded  as  a  great  misfortune  that  his  extant 
remains  are  so  meager. 

In  later  times  many  Egyptian  physicians  practiced  in  Rome ;  for  to 
have  studied  in  the  land  of  the  Nile,  or,  still  better,  to  have  been  bom 
there,  was  regarded  as  a  special  recommendation.  Here,  too,  magic 
formulas  of  all  kinds  were  in  frequent  use,  not  only  in  the  compound- 
ing of  medicines,  but  in  their  application.  According  to  Pliny  cadavers 
were  dissected  by  order  of  the  Ptolemies  for  the  purpose  of  studying 
fatal  diseases.  But  it  can  hardly  be  inferred  from  this  statement  that 
anatomy  was  regularly  pursued  in  this  way,  or  that  dissection  was  a 
common  practice. 

Pliny,  who  had  no  very  high  opinion  of  the  medical  fraternity  for 
reasons  that  will  appear  farther  on,  makes  the  assertion  that  Rome 
managed  to  get  along  six  hundred  years  without  physicians.  This  is 
manifestly  an  exaggeration,  since  many  Greeks  professed  the  healing 
art  in  the  imperial  city  much"  earlier  than  150  B.  C.  But  neither  did 
Rome  produce  a  philosopher  in  the  proper  sense  of  the  term ;  certainly 
no  man  who  loved  wisdom  for  its  own  sake.  The  Romans  were,  how- 
ever, an  exceptionally  healthy  people,  owing  to  their  fondness  for  out- 
door life.  This  is  demonstrated  by  the  rapidity  with  which  they  recov- 
ered from  repeated  disasters.  Once  in  a  while  their  capital  was  invaded 
by  a  contagious  disorder,  then  all  who  could  do  so  left  it  until  the 
scourge  had  spent  its  force,  when  affairs  resumed  their  natural  channel. 
In  fact  this  was  the  usual  course  everywhere  until  very  recently,  when 
the  real  nature  of  such  diseases  was  discovered.  The  ancient  Romans 
were  also  a  singularly  hard-headed  and  practical  people ;  consequently 


PHYSICIANS  AND  PHILOSOPHERS.  276 

they  were  almost  entirely  free  from  the  long  list  of  complaints  that 
are  more  or  less  due  to  the  uncontrolled  or  uncontrollable  imagination. 
Shortly  after  the  Punic  wars,  but  especially  under  the  empire  when 
luxurious  habits  due  to  the  influx  of  wealth  from  the  east  had  debili- 
tated the  naturally  robust  constitutions  of  the  higher  classes,  nervous 
disorders,  along  with  many  others,  were  inevitable.  Then  quacks, 
charlatans,  medicasters,  soothsayers,  magicians,  astrologers  and  what 
not  found  a  ready  market  for  their  wares.  They  played  upon  the  cre- 
dulity of  the  populace  and  preyed  upon  their  purses  because  there  was 
money  in  both  the  playing  and  the  preying.  No  small  portion  of  them 
probably  were  shrewd  enough  to  disguise  some  real  medical  knowledge 
under  a  mass  of  hocus  pocus  in  order  to  influence  the  imaginations  of 
their  patients.  Well  might  Ovid  say  as  others  had  said  before  him — 
and  since,  too—mundus  vult  decipi  (people  like  to  be  deluded).  Phy- 
sicians still  give  to  their  patients  who  insist  'on  taking  something'  bread 
pills,  colored  water  and  other  equally  potent  or  impotent  remedies.  It 
would  be  manifestly  unfair  to  charge  a  physician  with  dishonesty 
because  he  practices  a  harmless  ruse  upon  a  patient  who  can  be  helped 
in  no  other  way  so  easily. 

"Dismissing  faith  in  the  confused  creeds  of  the  heathen  world,  he 
reposed  the  greatest  faith  in  the  power  of  human  wisdom.  He  did 
not  know  (perhaps  no  one  in  that  age  distinctly  did)  the  limits  which 
nature  imposes  on  our  discoveries.  Seeing  that  the  higher  we  mount 
in  knowledge  the  more  wonders  we  behold,  he  imagined  that  nature  not 
only  worked  miracles  in  her  ordinary  course,  but  that  she  might,  by 
the  cabala  of  some  master  soul,  be  diverted  from  that  course  itself. 
Thus  he  pursued  science  across  her  appointed  boundaries  into  the  land 
of  perplexity  and  shadow.  From  the  truths  of  astronomy  he  wandered 
into  astrological  fallacy ;  from  the  secrets  of  chemistry  he  passed  into 
the  spectral  labyrinth  of  magic;  and  he  who  could  be  skeptical  as  to 
the  power  of  the  gods  was  credulously  superstitious  as  to  the  power 
of  man."  Such  are  the  thoughts  that  Bulwer-Lytton,  in  the  Last  Days 
of  Pompeii,  puts  into  the  mind  of  one  of  his  characters,  the  Egyptian 
Arbaces.  The  reasoning  by  which  such  men  justified  the  employment 
of  their  superioi:  knowledge  and  insight  to  dupe  the  credulous  was 
half  philosophy,  half  knavery.  If  a  man  is  the  possessor  of  power 
unknown  to  the  multitude  except  in  its  effects,  why  has  he  not  the 
right  to  use  it? — to  use  it  first  of  all  to  enhance  his  authority  and  to 
draw  from  such  authority  the  advantages  that  seem  to  him  most  desir- 
able ?  We  may  well  admit  that  a  man  of  this  stamp  may  have  had  an 
inward  feeling  akin  to  what  we  call  conscience  that  would  justify  his 
attitude  toward  his  fellows — ^yet  he  did  not  consider  these  Romans 
fellow  men  of  his — but  it  was  wholly  of  the  intellect.  Such  a  man  is 
as  much  a  philosopher  as  were  the  sophists  of  an  earlier  age,  and,  we 
may  add,  of  our  own  day.  They  apprehend  clearly  certain  superficial 
verities,  but  cease  to  inquire  farther  after  they  have  discovered  what 


276  EDITORIAL  COMMENT. 

they  think  needful  and  sufficient  for  their  own  aggrandizement  Far 
different  was  the  class  of  witches,  one  of  whom  is  introduced  in  the 
same  novel.  Against  these  Horace  frequently  raises  his  voice,  as  do 
also  others  of  the  rationalizing  Romans.  They  are  ignorant,  and,  in 
most  instances,  as  much  the  dupes  of  their  own  juggleries  as  their 
victims.  Every  man  who  goes  through  the  world  with  his  mind  alert 
can  see  specimens  without  especially  looking  for  them.  It  is  doubtful 
whether  any  man  has  ever  lived  who  had  not  at  least  a  modicum  of 
superstition  in  him.  However  much  we  may  know  and  however  far 
we  may  be  able  to  pry  into  nature  in  some  directions,  there  are  others 
in  which  our  vision  is  barred  and  the  unknown  is  literally  within  arm's 
length.  The  mystery  of  life  and  death  has  always  been  so  profound, 
as  it  still  is,  though  in  a  different  way,  that  we  need  not  wonder  at  the 
strange  aberrations  which  so  many  persons  fell  into,  who  were  in  most 
matters  little  likely  to  be  carried  away  by  delusions.  Sleep,  'the  twin 
brother  of  death,'  has  from  time  out  of  mind  been  regarded  as  an 
excursion  into  the  realm  of  departed  spirits.  If,  as  many  believe,  our 
consciousness  is  never  coextensive  with  our  personality,  there  are  yet 
many  discoveries  to  be  made  not  dreamt  of  in  the  philosophy  of  most 
of  us.  Our  will  as  an  integral  part  of  ourselves  is  the  resultant  of  so 
many  forces  and,  with  the  majority,  is  so  little  under  control  of  rational 
motives,  that  it  often  plays  fantastic  tricks,  not  before  high  heaven 
alone,  but  almost  anywhere. 

The  will  of  each  individual  as  modified,  at  least  in  action  from 
moment  to  moment,  is  like  a  ball  thrown  into  a  grove.  It  strikes  one 
tree,  then  another  and  another,  and  no  one  can  predict  with  certainty 
where  it  will  come  to  rest.  This  element  of  chance,  of  Tyche,  in  the 
affairs  of  men,  this  incalculable  calculus  of  probabilities,  pervades  in 
a  remarkable  degree  the  literature  of  ancient  Greece  and  Rome.  It 
made  many  feel  that,  do  what  they  would,  they  were  doomed  to  be 
thwarted  in  their  plans.  It  was  only  those  who,  like  Socrates,  Epictetus 
and  a  few  others,  maintained  that  the  chief  end  of  man  is  to  be  found 
in  motives  rather  than  in  outward  results,  who  were  never  thrown  out 
of  their  philosophical  poise  by  the  strange  vicissitudes  of  life. 

It  is  a  far  cry  from  the  Greeks  to  the  Saracens,  though  farther  in 
time  than  in  space.  Here  we  find  philosophy,  or  rather  metaphysics, 
and  medicine  more  intimately  associated  than  at  any  other  time  or 
among  any  other  people.  Every  one  of  the  ten  or  twelve  men  who 
became  prominent  in  Arabian  philosophy  was  a  physician.  In  fact  the 
Arabs  treated  philosophy  as  a  branch  of  astronomy  and  the  healing  art. 
The  latter  served  a  practical  purpose,  as  did  also  the  former  in  so  far  as 
it  was  dealt  with  as  astrology.  Arab  philosophy  was,  however,  some- 
thing very  different  from  the  science  that  bore  the  same  name  among 
the  Greeks.  They  studied  philosophy,  or  rather  they  philosophized, 
as  a  man  would  study  navigation  on  a  ship  lying  at  anchor.  Albeit 
they  were  in  this  respect  at  no  greater  disadvantage  than  the  school- 
men.    The  one  party  was  chiefly  concerned  to  make  any  discoveries 


PHYSICIANS  AND  PHILOSOPHERS'.  277 

they  might  light  upon  hannonize  with  the  Koran  and  Aristotle;  the 
other  with  the  Bible  and  Aristotle,  with  a  little  spice  from  Ptolemy 
thrown  in.  Al-ldndi,  the  philosopher  par  excellence  of  the  Arabs, 
flourished  in  the  tenth  century.  He  wrote  on  almost  every  imaginable 
subject  from  arithmetic  to  astronomy,  though  under  the  former  he  dis- 
cusses the  unity  of  God ;  his  arithmetic  was  therefore  something  totally 
different  from  that  which  forms  the  schoolboy's  triangle  with  readin' 
and  'ritin'.  So  far  as  is  at  present  known  all  his  works  are  lost,  except 
those  on  medicine  and  astrology.  Roger  Bacon  ranks  him  in  some 
respects  close  to  Ptolemy.  Al-farabi  was  a  contemporary  of  the  pre- 
ceding and  is  generally  regarded  as  the  earliest  of  the  Arabian  philos- 
ophers. However,  medical  science  and  even  surgery  could  make  little 
progress  where  the  knowledge  of  human  anatomy  was  so  inadequate. 
The  Koran  denounces  as  unclean  every  person  who  touches  a  dead 
body,  and  an  article  of  Mohammedan  faith  forbids  dissection.  We 
should  remember,  nevertheless,  that  the  founder  of  anatomy,  Vesalius, 
was  sentenced  to  death  by  the  Inquisition  as  a  magician,  and  only  par- 
doned on  condition  that  he  make  a  pilgrimage  of  penance  to  Jerusalem. 
This  journey  cost  him  his  life.  And  it  is  probable  that  he  would  not 
have  got  off  even  on  these  relatively  hard  terms  had  he  not  enjoyed  the 
favor  of  Philip  H  of  Spain,  who  esteemed  him  highly  for  his  medical 
skill.  We  have  the  name  of  one  Arab  physician,  Abdallatif  of  Bagdad, 
who  was  well  aware  that  anatomy  could  not  be  learned  from  books, 
strange  as  it  may  seem  that  historians  have  thought  it  worth  while  to 
place  to  any  man's  credit  a  truth  so  easily  apprehended.  The  same 
authority  avers  that  Moslem  doctors  studied  that  branch  of  anatomy 
known  as  osteology  by  examining  the  bones  of  the  dead  found  in  cem- 
eteries. Averroes  of  Cordova  fills  a  large  place  in  the  history  of  Moor- 
ish philosophy  in  Spain  about  the  middle  of  the  twelfth  century.  But 
in  medical  renown  he  ranks  far  below  Avicenna  of  Bokhara,  who 
flourished  about  a  century  and  a  half  earlier.  He  was  teacher  of  both 
philosophy  and  medicine  in  Ispahan.  His  medical  works  seem  to  have 
been  the  chief  guide  in  this  branch  in  Europe  for  almost  five  centuries  ; 
their  sway  was  not  broken  until  the  beginning  of  the  seventeenth  cen- 
tury. It  is  strong  and  yet  painful  testimony  to  the  inherent  stupidity  of 
mankind,  physicians  not  excepted,  that  the  doctrines  of  Avicenna  are 
little  more  than  what  is  found  in  Galen  somewhat  modified  by  Aris- 
totle ;  and,  as  we  have  seen,  Galen  represents  no  great  advance  upon 
Hippocrates.  Alas  for  the  human  race  that  it  has  always  been  so  much 
easier  to  memorize  than  to  think  and  to  investigate!  The  medical 
science  and  practice  of  the  Arabs  was  confined  chiefly  to  surgery  and 
the  empirical  treatment  of  internal  diseases.  There  was  no  lack  of 
victims  in  view  of  the  constant  wars  in  which  the  califs  were  engaged, 
and  no  lack  of  opportunity  for  the  study  of  disease  in  its  various  forms 
in  the  hospitals  which  some  of  them  founded  in  various  parts  of  their 
domains. 

[TO  Bl  CONTINUED.] 


278  MEDICAL  NEWS. 

MEDICAL  NEWS. 


THE  NATIONAL  MEDICAL  ELECTION: 

Doctor  Joseph  D.  Bryant,  of  New  York  City,  was  elected  pres- 
ident of  the  American  Medical  Association  at  its  recent  meeting  in 
Boston.  Other  officers  chosen  on  this  occasion  are  as  follows:  First 
vicepresident,  Doctor  Herbert  L.  Burrell,  of  Boston;  second  vice- 
president,  Doctor  Andrew  C.  Smith,  of  Portland ;  third  vicepresident, 
Doctor  David  S.  Fairchild,  of  Des  Moines;  fourth  vicepresident. 
Doctor  William  S.  Foster,  of  Pittsburgh;  general  secretary,  Doctor 
George  H.  Simmons,  of  Chicago ;  treasurer,  Doctor  Frank  Billings,  of 
Chicago;  trustees,  Doctor  Malcolm  L.  Harris,  of  Chicago,  DoctcM* 
William  H.  Welch,  of  Baltimore,  and  Doctor  Miles  F.  Porter,  of  Fort 
Wayne. 

COMMENCEMENT  SEASON  CLINIC. 

Clinic  week  is  always  an  important  feature  of  commencement  sea- 
son at  the  Detroit  College  of  Medicine,  but  the  event  this  year  is 
pronounced  more  consequential  than  ever  before,  as  many  as  three 
hundred  witnessing  some  of  the  clinics,  and  five  hundred  being  con- 
servatively estimated  as  the  total  attendance.  In  addition  to  the  regular 
teaching  force  of  the  college,  clinics  were  conducted  by  Doctor  George 
Dock,  of  Ann  Arbor,  on  diseases  of  the  heart;  Doctor  Edward  G. 
Tuttle,  of  New  York,  on  rectal  diseases;  Doctor  Bart  E.  MacKenzie, 
of  Toronto,  on  orthc^dic  surgery;  and  Doctor  Howard  A.  Kelly,  of 
Baltimore,  on  operative  gynecology.  The  advent  of  the  scientific  and 
social  features  of  the  occasion  was  marked  by  a  symposium  on  "Crim- 
inal Abortion"  before  the  Wayne  County  Medical  Society,  the  partici- 
pants being  Doctor  Howard  W.  Longyear,  of  Detroit,  who  discussed 
the  question  from  the  medical  standpoint ;  Attorney  Charles  Lightner, 
of  Detroit,  who  considered  the  legal  aspect  of  the  question ;  and  Rev- 
erend Father  Command,  of  Trenton,  who  defined  the  attitude  of  the 
Church  toward  the  murderous  practice. 


THE  PENINSULAR  GATHERING  OF  PHYSICIANS. 

The  forty-first  annual  meeting  of  the  Michigan  State  Medical 
Society  was  held  at  Jackson,  May  23,  24,  and  25.  The  program 
embraced  the  titles  of  over  fifty  papers,  besides  three  orations  and  two 
addresses,  the  latter  being  delivered  by  Doctor  John  B.  Murjrfiy,  of 
Chicago,  and  President  David  Inglis,  of  Detroit.  "Education"  was 
the  subject  of  the  presidential  discourse,  and  the  views  enunciated  con- 
template not  only  better  means  of  educating  the  physician  but  better 
means  of  educating  the  public  as  well.  The  trend  of  ideas  is  especially 
reflected  in  the  suggestion  that  county  societies  disseminate  informa- 


LIFE  INSURANCE  EXAMINATION  FEES.  279 

tion  among  the  laity  regarding  the  prophylaxis  of  venereal  diseases; 
that  a  committee  on  medical  educaticm  be  appointed  from  the  State 
Society  to  cooperate  with  the  Q>uncil  of  the  American  Medical  Asso- 
ciation; that  amalgamation  of  medical  schools  affords  the  greatest 
efficiency  in  properly  training  medical  students,  and  hence  the  desira- 
bility in  Michigan  of  merging  the  State  University  medical  school  and 
the  Detroit  College  of  Medicine.  The  quality  of  the  papers  was  equal 
to  the  average  of  previous  meetings,  while  the  symposiums  in  the 
sections  afforded  exceedingly  delightful  variation.  The  Society 
recommended  the  c(xnbination  of  medical  colleges;  addition  to  the 
faculties  of  medical  colleges  of  a  chair  on  Professional  Ethics ;  investi- 
gation of  contract  practice  for  fraternal  orders  and  for  poor  commis- 
sioners ;  refusal  to  accept  reduction  of  fees  for  life  insurance  examina- 
tions ;  and  modification  of  existing  laws  to  enable  more  efficient  deal- 
ing with  tuberculous  cattle.  It  was  decided  to  return  to  a  two-days' 
session  and  to  omit  the  orations.  A  vote  of  thanks  was  tendered 
Doctor  Leartus  Connor  for  services  rendered  in  reorganizing  the  State 
Society,  and  a  committee  was  appointed  to  select  a  testunonial  for 
Doctor  Andrew  P.  Biddle  in  recognition  of  his  services  as  secretary. 
The  following  officers  were  elected  for  the  ensuing  year:  President, 
Doctor  Charles  B.  Stockwell,  of  Port  Huron ;  first  vicepresident.  Doctor 
William  Fuller,  of  Grand  Rapids ;  second  vicepresident.  Doctor  Edward 
T.  Abrams,  of  Dollar  Bay;  third  vicepresident,  Doctor  Delbert  Rob- 
inson, of  Jackson;  fourth  vicepresident.  Doctor  Allison  R,  Stealy,  of 
Charlotte.  The  following  were  elected  chairmen  of  sections:  Med- 
icine— ^Doctor  Joseph  B.  Whinery,  of  Grand  Rapids ;  Surgery — ^Doctor 
Louis  A.  Roller,  of  Grand  Rapids;  Gynecology — Doctor  Walter  H. 
Sawyer,  of  Hillsdale.    The  next  meeting  will  be  held  at  Saginaw. 


LIFE  INSURANCE  EXAMINATION  FEES. 

The  question  of  compensation  for  life  insurance  examinations  was 
considered  at  the  recent  Jackson  meeting  of  the  Michigan  State  Medical 
Society,  and  the  concensus  of  opinion  was  expressed  in  the  following 
preamble  and  resolutions:        ' 

Whereas,  Many  of  the  Life  Insurance  Companies  havQ  notified  their 
medical  examiners  of  a  reduction  of  the  examining  fee  from  $5.00  to 
$3.00,  and 

Whereas,  We,  as  physicians,  realizing  the  responsibility  incident  to 
proper  examination  of  the  individual,  believe  such  reduction  to  be 
unjust,  therefore,  be  it 

Resolved,  That  the  House  of  Delegates,  in  session  assembled,  does 
hereby  declare  such  reduction  to  be  unjust,  and  respectfully  requests 
that  no  physician  legally  authorized  to  practice  medicine  in  Michigan, 
accept  such  reduction  of  fees. 

Resolved,  That  it  is  the  sense  of  the  House  of  Delegates  that  here- 
after in  such  examinations  for  life  insurance,  the  minimum  fee  shall 
be  $5.00. 


280  MEDICAL  NEWS. 

Resolved,  That  the  several  component  societies  forming  this  State 
Society,  be  requested  to  adopt  these  resolutions. 

Resolved,  That  a  copy  of  these  resolutions  be  mailed  to  the  several 
life  insurance  companies  that  have  reduced  the  fee  from  $5.00  to  $3.00. 

At  the  Boston  meeting  of  the  American  Medical  Association,  Doctor 
Mayo,  in  his  presidential  address,  referred  to  the  question  of  fees  for 
life  insurance  examinations  in  the  following  terms : 

"We  come  now  to  consider  some  abuses  from  which  the  physician 
suffers.  It  is  a  matter  of  professional  pride  that,  in  the  general  con- 
demnation of  the  life  insurance  companies,  although  every  other  part 
of  the  control  has  been  shown  to  be  corrupt,  no  breath  of  scandal  has 
touched  the  medical  department.  Yet  the  local  examiner  has  the  most 
cause  of  all  to  be  dissatisfied.  The  New  York  Life,  some  years  ago, 
cut  the  fee  for  examination  forty  per  cent,  apparently  not  as  a  matter 
of  ecgnomy,  for  at  that  time  the  most  corrupt  practices  existed,  but 
rather  to  enable  the  agent  more  easily  to  pass  'new  business'  at  any 
cost.  This  action  has  lately  been  imitated  by  the  Equitable  and  some 
others  and  has  resulted  in  forcing  the  resignation  of  many  of  their  best 
examiners.  The  general  officers  have  taken  great  credit  on  themselves 
for  voluntarily  reducing  their  salaries  twenty  per  cent.  It  is  a  rank 
injustice  that  the  one  body  of  men  who  have  emerged  clean  from  the 
insurance  scandals  should  suffer  the  most  for  the  crimes  of  others. 
A  thorough  medical  examination  to  prevent  fraud  by  the  admission  of 
unsafe  risks  is  essential.  With  few  exceptions  the  line  companies  pay 
a  fair  fee  and  less  should  not  be  accepted.  The  casualty  Companies, 
such  as  the  Maryland,  are  the  worst  offenders,  and  some  concerted 
action  should  be  taken  to  compel  them  to  mend  their  evil  ways." 

Acting  upon  the  suggestion  of  the  President  the  following  resolu- 
tion was  introduced  and  referred  to  the  Committee  on  Miscellaneous 
Business : 

Resolved,  That  a  standing  committee  on  insurance  is  hereby  created 
to  consist  of  five  members,  two  of  whom  shall  be  the  President  and 
Secretary,  and  the  other  three  to  be  nominated  by  the  President  and 
confirmed  by  this  House  of  Delegates.  It  shall  be  th  duty  of  the  com- 
mittee to  consider  the  relations  and  duties  of  the  medical  profession  of 
this  country  to  the  insurance  business,  both  companies  and  policy 
holders  to  confer,  treat  and  act  with  authorized  representatives  of  any 
of  these  interests,  and  it  is  authorized  to  speak  and  act  for  the  profes- 
sion in  all  matters  relating  to  its  duties  and  to  give  publicity  to  its 
plans  and  purposes  at  any  time  through  The  Journal,  or  otherwise,  as 
may  be  deemed  best. 

This  committee,  which  includes,  besides  the  President  and  Secretary, 
Doctors  E.  Elliot  Harris,  Albert  D.  Price,  and  William  D.  Haggard, 
submitted  the  following  resolution  to  the  House  of  Delegates : 

Resolved,  That  a  committee  be  created  to  consist  of  five  members, 
two  of  whom  shall  be  the  President  and  the  President-elect  and  the 


LIFE  INSURANCE  EXAMINATION  FEES.  881 

Other  three  to  be  nominated  by  the  President  and  confirmed  by  the 
House  of  Delegates. 

That  they  shall  consider  the  insurance  question  in  its  relation  to  the 
medical  profession,  and  it  shall  have  power  to  act  and  confer  with  the 
representatives  of  the  insurance  cc«npanies  and  policy-holders  on  behalf 
of  the  medical  profession  represented  by  this  Association. 

It  shall  give  publicity  to  its  plans  and  purposes  at  any  time  in  The 
Journal  or  as  may  be  deemed  best. 

That  the  resolution  of  Doctor  D.  M.  Work,  of  Colorado,  asking  for 
an  endorsement  in  the  matter  of  the  examination  fee  question  which 
has  been  confirmed  by  many  county  medical  societies. 

That  the  Committee  recommends  that  it  is  in  spirit  with  it ;  yet  in 
view  of  the  fact  that  a  committee  is  created  to  deal  with  these  questions, 
it  asks  that  the  resolution  in  question  be  referred  to  the  Committee  on 
Insurance. 

The  following  Committee  on  Insurance  was  tjien  appointed  by  the 
Chair: 

John  H.  Musser,  Pennsylvania,  Chairman ;  William  H.  Mayo,  Min- 
nesota; Joseph  N.  MacCormack,  Kentucky;  Joseph  D.  Bryant,  New 
York;  Frank  Billings,  Illinois. 

The  resolution  of  Doctor  Work  alluded  to  in  the  resolutions  of  the 
Committee  on  Miscellaneous  Business,  is  as  follows: 

Resolved,  That  the  American  Medical  Association  heartily  endorses 
the  action  of  many  of  its  component  county  societies  in  their  refusing 
to  accept  a  reduction  of  the  fees  heretofore  paid  for  life  insurance 
examinations  by  certain  so-called  old-line  companies. 

This  is  the  status  of  the  matter  as  considered  by  the  Michigan  State 
and  American  Medical  Associations.  At  the  seventh  annual  meeting 
of  the  American  Association  of  Life  Insurance  Examining  Surgeons, 
which  was  lately  held  in  Boston,  the  question  of  fees  was  discussed. 
This  association  is  composed  of  physicians  who  are  closely  identified 
with  the  present  agitation,  and  consequently  the  following  preambles 
and  resolution,  adopted  by  that  body,  will  be  of  exceeding  interest : 

Whereas,  It  is  generally  understood  by  every  practitioner  through- 
out the  country  that  the  examiner  who  does  his  full  duty  must  often 
cause  the  rejection  of  undesirable  risks  and  the  consequent  loss  of  busi- 
ness to  the  company  and  of  commissions  to  the  soliciting  agent;  and, 

Whereas,  The  interests  of  the  insured  and  the  welfare  of  the  com- 
pany represented  by  the  examiner  make  it  necessary  for  him  to  exercise 
his  judgment,  to  make  a  careful  diflFerentiation  of  risks  and  to  try  by 
every  means  in  his  power  to  recommend  only  those  applicants  whose 
physical  condition  is  up  to  the  standard  and  whose  examination  dis- 
closes no  undue  influence  which  might  prevent  the  living  out  of  the 
estimated  expectancy;  and, 

Whereas,  Recent  disclosures  in  connection  with  life  insurance  aflFairs 
have  demonstrated  (i)  inexcusable  negligence,  (2)  criminal  careless- 
ness,  (3)   dishonest  practices  on  the  part  of  the  highest  executive 


282  MEDICAL  NEWS. 

officers,  and  a  total  abandonment  of  the  responsibility  always  pertaining 
to  a  trusteeship,  in  a  concerted  e£Fort  for  personal  profit ;  therefore  be  it 

Resolved,  That  we  favor  the  complete  separation  of  the  medical 
from  the  executive  department  of  every  mutual  insurance  company. 

We  favor  the  election  of  the  medical  director  in  the  same  way  and 
manner  as  the  election  of  the  executive  officers,  namely,  by  diro:t  vote 
of  the  policy-holders. 

We  favor  suitable  legislation  in  all  States,  with  a  view  of  making 
this  recommendation  effective. 

We  depreciate  the  action  on  the  part  of  certain  state  and  country 
medical  societies  to  assert  that  members  shall  be  expelled  from  mem- 
bership or  shall  be  deprived  of  the  privilege  of  consultation  with  their 
fellows  unless  they  agree  under  no  circumstances  to  make  an  examina- 
tion for  less  than  $5.  We  agree  that  a  reduced  fee  is  inadequate  to 
the  value  of  the  service  rendered,  but  we  assert  that  no  hardship  should 
be  imposed  upon  the  individual  practitioner.  We  favor  in  place  of  this, 
to  enter  an  earnest  protest  against  the  attempt  of  certain  companies  to 
reduce  the  fee.  We  assert  most  positively  that  economy  in  insurance 
methods  should  not  begin  with  the  medical  examiners — ^it  should  take 
cognizance  of  the  irregularities — ^to  use  no  harsher  word — ^which  the 
Armstrong  investigation  has  brought  to  light  It  should  favor  reform, 
but  it  must  maintain  an  efficient  corps  of  medical  examiners,  which  is 
only  possible  by  paying  a  fee  to  some  degree  commensurate  with  the 
importance  of  the  service  rendered. 


MINOR  INTELLIGENCE. 


Doctors  Charles  D.  Aaron  and  Gilbert  S.  Field,  two  Detroit 
physicians,  are  in  Europe. 

The  next  meeting  of  the  American  Medical  Association  will  be 
held  at  Atlantic  City,  New  Jersey. 

The  osteopathic  licensing  bill,  which  recently  passed  the  New  York 
Senate,  was  afterward  revoked  by  the  Assembly. 

Doctor  Hal  C.  Wyman,  of  Detroit,  and  Miss  Lulu  Weeks,  of 
Mount  Vernon,  New  York,  were  united  in  marriage  on  June  12,  at 
the  home  of  the  bride. 

An  amalgamation  of  the  old  territorial  medical  associations  of 
Oklahoma  and  Indian  Territory  has  been  effected,  and  the  new  organ- 
ization will  henceforth  be  known  as  the  Oklahoma  State  Medical 
Association. 

This  year's  meeting  of  the  British  Medical  Association  will  be 
held  in  Toronto,  Canada,  ^rom  August  21  to  25.  A  large  attendance 
is  anticipated  both  from  England  and  from  the  United  States.  The 
address  in  Medicine  will  be  delivered  by  Sir  James  Barr,  and  the 
address  in  Surgery  by  Sir  Victor  Horsley. 


MINOR    INTELLIGENCE.  283 

Doctor  F.  F.  Westbrook  has  been  elected  to  the  deanship  of  the 
Minnesota  University  department  of  medicine  and  surgery,  vice  Doctor 
Parks  Ritchie,  resigned. 

Doctor  George  Blumer,  formerly  professor  of  pathology  and  bac- 
teriology in  the  Albany  Medical  College,  has  been  appointed  to  fill  the 
chair  of  medicine  at  Yale  University. 

A  BILL  appropriating  a  total  of  $350,000,  or  $50,000  annually  for 
seven  years,  for  the  work  of  exterminating  the  mosquito  has  been 
signed  by  Governor  Stokes  of  New  Jersey. 

The  Order  of  the  Rising  Sun  has  been  cgnferred  upon  Doctor 
Jokichi  Takamine,  the  well-known  Japanese  chemist  of  New  York 
City,  by  His  Majesty,  the  Emperor  of  Japan. 

Plague  continues  to  reap  a  fearful  harvest  in  India.  During  the 
week  ending  April  28  over  one  thousand  seven  hundred  deaths  out  of 
a  possible  twenty  thousand  cases  were  reported. 

Doctor  Bacon,  a  prominent  Connecticut  physician  who  died 
recently,  left  a  legacy  of  $100,000  to  the  Hartford  Medical  Society. 
The  bequest  will  be  utilized  as  an  endowment  fund. 

Doctor  Theodore  A.  Felch,  of  Ishpeming,  has  been  appointed  a 
member  of  the  Michigan  State  Board  of  Registration  in  Medicine,  vice 
Doctor  Joseph  B.  Griswold,  of  Grand  Rapids,  resigned. 

Mayor  McClellan,  of  New  York  City,  has  appointed  a  commission 
to  cooperate  with  a  like  body  from  Jersey  City  in  the  establishment  of 
protection  of  the  waters  of  the  harbor  against  pollution. 

The  Health  Department  of  Chicago  will  shortly  gain  possession 
of  the  eight  municipal  ambulances  which  have  been  under  police  con- 
trol.   The  vehicles  will  then  be  under  medical  supervision. 

The  new  medical  buildings  of  Harvard  University  will  be  dedicated 
this  fall,  the  ceremonies  being  scheduled  for  September  25  and  26, 
1906.    Faculty  invitations  have  already  been  issued  to  alumni. 

Doctor  Albert  Becket  Lamp,  formerly  of  Harvard  University, 
has  been  appointed  to  the  directorship  of  the  Havemeyer  Laboratory 
of  Chemistry,  New  York  University,  vice  Doctor  Morris  Loeb. 

In  connection  with  the  opening  of  the  new  cancer  research  labora- 
tory at  Heidelberg,  an  international  congress  on  the  subject  is  con- 
templated.   The  event  will  be  held  from  September  24  to  27,  1906. 

Doctor  Charles  W.  Pilgrim7  until  recently  superintendent  of  the 
Hudson  River  State  Hospital,  has  been  appointed  to  the  presidency 
of  the  New  York  State  Lunacy  Commission,  vice  Doctor  William 
Mabon,  resigned. 

The  great  prevalence  of  typhoid  in  Pittsburg  and  vicinity  has  led 
the  Pennsylvania  Commissioner  of  Health  to  demand  that  the  cities  and 
villages  situate  on  the  tributaries  of  the  Allegheny  disinfect  all  refuse 
before  dumping  it  into  the  streams. 


284  MEDICAL  NEWS. 

The  American  Journal  of  the  Medical  Science  which,  untfl  recently, 
has  been  under  the  editorial  control  of  Doctor  Francis  R.  Packard, 
will  henceforth  be  guided  by  Doctor  Aloysius  O.  J.  Kelly,  who  has 
been  elevated  to  the  editorial  tripod. 

Professor  Wilhelm  Ostwald  has  resigned  the  chair  of  chemistry 
at  the  University  of  Leipzig.  Displeasure  caused  by  the  indifference  of 
coworkers  at  the  institution  toward  his  chemical  researches  is  said  to 
be  the  reason  for  the  relinquishment. 

Milwaukee  has  an  ordinance  which  compels  physicians  to  report 
injuries  which  incapacitate  the  victom  for  a  period  of  two  weeks  or 
longer.  An  average  of  more  than  one  hundred  seventy-five  a  month 
has  been  recorded  thus  far  this  year. 

The  Lyman  D.  Morse  Advertising  Agency,  well-known  medical 
advertising  purveyors,  has  increased  its  scope,  and  will  henceforth 
be  known  as  the  Morse  International  Agency,  with  offices  at  19  West 
Thirty-fourth  Street,  New  York  City. 

The  effectiveness  of  the  sanitary  regime  instituted  by  the  Amer- 
icans in  the  canal  zone  is  apparent.  According  to  the  last  official  report, 
that  region  was  infested  with  only  one  case  of  yellow  fever,  and  disease 
of  all  kinds  is  rapidly  being  eradicated. 

The  House  of  Representatives  passed  the  Pure  Food  bill  by  a  vote 
of  240  to  17  on  the  23d  instant.  The  enactment  differs  considerably 
from  the  original  measure  proposed  by  the  senate,  having  been  subjected 
to  the  adoption  of  several  amendments. 

The  recent  death  of  Doctor  Louis  A.  Wiegel,  of  Rochester,  New 
York,  from  burns  received  in  experimenting  with  the  ;r-rays,  should 
serve  as  a  warning  against  undue  exposure,  especially  of  the  hand, 
when  operating  radiographic  apparatus. 

The  Minnesota  State  Board  of  Health  has  decreed  that  henceforth 
tuberculous  teachers  shall  not  be  employed,  inasmuch  as  confinement 
in  school  buildings  not  only  militates  against  the  recovery  of  teachers 
but  endangers  the  health  of  the  children  as  well. 

The  plaintiff  .in  a  damage  suit  which  recently  occurred  in  Nebraska 
was  granted  a  verdict  for  $600  against  a  physician  for  injuries  allied 
to  have  been  received  in  an  jr-ray  examination  for  the  detection  of  a 
vesical  calculus.    Damages  to  the  extent  of  $6,000  were  claimed. 

Doctor  John  J.  Marker  has  been  reappointed  general  superin- 
tendent of  the  Wayne  County  Home  at  Eloise.  Other  positions  filled 
by  the  Superintendents  of  the  Poor  are:  assistant  superintendent, 
Doctor  William  B.  James ;  house  physician.  Doctor  Romeo  H.  Earl. 

A  SOCIETY  for  the  promotion  of  cremation  has  been  formed  in 
Belgium.  Inasmuch  as  this  method  of  disposal  has  not  gained  foothold 
to  an  appreciable  degree  in  that  country  the  new  organization  will 
conduct  a  campaign  by  means  of  lectures,  tracts,  expositions,  et  cetera. 


MINOR  INTELLIGENCE.  286 

The  French  government  has  accorded  Madame  Curie,  wife  of  the 
discoverer  of  radium,  a  pension  of  12,000  francs  per  annum.  Besides 
this  income  she  will  have  the  salary  connected  with  the  chair  of  Physics, 
in  the  University  of  Paris,  to  which  she  has  recently  been  appointed. 

The  Philadelphia  Board  of  Education  is  agitating  the  advisability 
of  employing  a  corps  of  trained  nurses  to  work  among  the  school 
children  of  that  city.  Because  of  the  appropriation  incident  to  the 
departure,  such  a  bill  would  be  likely  to  receive  a  negative  vote  in  the 
city  council. 

The  Buffalo  city  hospital  for  the  care  of  patients  suflFering  from 
contagious  diseases  is  rapidly  nearing  completion.  The  erection  of 
the  new  building  has  necessitated  an  expenditure  of  over  $50,000,  and 
in  range  of  equipment  the  institution  will  be  one  of  the  best  appointed 
in  the  state. 

The  study  of  alcoholism  has  been  introduced  into  the  curriculum 
of  the  University  of  Berlin.  The  subject  will  be  demonstrated  from 
all  phases — the  influence  of  alcoholic  indulgence  on  the  mental  develop- 
ment of  the  young,  its  relation  to  insurance,  its  effects  on  the  physical 
powers,  et  cetera. 

Cocktails  adulterated  with  wood  alcohol  are  responsible  for  two 
deaths  which  occurred  recently  in  Brooklyn,  New  York.  A  ten-gallon 
keg  of  the  wood  product  was  found  on  the  premises  of  the  saloonkeeper 
who  dispensed  the  decoction,  and  the  rascal  has  been  arrested  on  a 
charge  of  homicide. 

A  charter  was  recently  granted  in  New  York  to  the  American 
Institute  for  Scientific  Research,  which  had  its  inception  in  the  Society 
for  Psychical  Research.  The  new  body  was  organized  primaril]f  to 
investigate  conditions  of  abnormal  psychology  and  to  place  the  study 
on  a  scientific  foundation. 

New  Rochelle,  New  York,  is  to  have  a  new  hospital.  Mr.  C.  O. 
Iselin  has  pledged  himself  to  contribute  $40,000  toward  the  project, 
providing  the  citizens  of  the  town  subscribe  $60,000,  and  thereby 
facilitate  the  erection  of  a  modern  building.  Twenty  thousand  dollars 
has  already  been  collected. 

The  Pennsylvania  State  Board  of  Health  has  inaugurated  a  course 
of  instruction  for  persons  suffering  from  or  exposed  to  transmissible 
diseases.  The  knowledge  is  dispensed  by  means  of  circulars,  and  com- 
prises practices  regarding  the  care  of  afflicted  as  well  as  precautions 
calculated  to  insure  prevention. 

The  Chicago  Medical  Society  elected  the  following  officers  at  its 
annual  meeting  on  June  20:  President,  Doctor  George  W.  Webster; 
secretary,  Doctor  Robert  T.  Gillmore;  councilors,  Doctors  William  A. 
Evans,  Charles  S.  Bacon,  Frank  Billings,  Lewis  L.  McArthur,  and 
Farnand  Henrotin;  alternates,  Doctors  William  E.  Quine,  Henry  F. 
Lewis,  Winfield  S.  Harpole,  Brown  Pusey,  and  Theodore  Tieken. 


286  MEDICAL  NEWS. 

The  Dental  Alumni  Association  of  the  University  of  Pennsylvania 
has  erected  a  bronze  tablet  in  Dental  Hall  to  commemorate  the  late 
Doctor  Charles  J.  Essig,  one  of  the  country's  foremost  workers  in  the 
dcHnain  of  dentistry,  and  professor  of  dental  mechanics  and  metal- 
lurgy in  the  Quaker  institution. 

The  records  of  the  California  State  Medical  Society  were  lost  in 
the  recent  disaster.  As  a  peculiar  coincidence  the  society  met  in  San 
Francisco  on  April  17,  1906,  the  day  before  the  catastrophe,  and  on  the 
morning  of  the  i8th — in  front  of  the  ruined  convention  hall — ^the 
meeting  was  declared  adjourned. 

German  Southwest  Africa  is  to  be  converted  into  a  receiving 
station  for  tuberculous  Teutons.  Evidently  the  sanatorium  system  as 
conducted  in  Germany  has  not  produced  the  most  desiraUe  results, 
and  since  the  climatic  conditions  in  Germany's  portion  of  the  dark 
continent  are  ideal  for  the  consumptive,  the  government  has  decided 
to  test  the  plan  by  sending  a  number  of  afflicted  working  people  to  the 
continent. 

The  hospital  system  of  San  Francisco  suffered  severely  from  the 
recent  earthquake,  all  but  three  or  four  being  rendered  useless.  The 
Children's  Hospital  was  one  of  those  which  remained  intact,  and  its 
inmates  are  receiving  the  attention  of  Doctor  Hezadiah  Crabtree.  A 
Maternity  Hospital  has  been  established  at  Berkeley  University,  and 
prospective  mothers  are  thereby  assured  proper  care  during  the 
puerperium. 

The  Indiana  State  Medical  Association  held  its  annual  meeting  at 
Winona  Lake  on  May  23-25,  1906.  Following  are  the  officers  elected 
for  the  coming  year:  President,  Doctor  George  J.  Cook,  of  Indian- 
apolfs ;  vicepresidents,  Doctor  John  B.  Berteling,  of  South  Bend,  and 
Doctor  Charles  J.  Chittick,  of  Frankfort;  secretary,  Doctor  Frederick 
C.  Heath,  of  Indianapolis ;  treasurer,  Doctor  Albert  E.  Bulson,  Jr.,  of 
Fort  Wayne. 

The  medical  section  of  the  Newberry  Library,  Chicago,  has  been 
consolidated  with  the  John  Crerar  Library  of  the  same  city.  Together 
with  the  library  proper.  Doctor  Senn  has  given  permission  for  the 
transfer  to  the  Crerar  Library  of  the  Senn  Collection  on  Medical  His- 
tory. At  present  the  quarters  of  the  John  Crerar  Library  are  inade- 
quate to  accommodate  the  change,  and  a  new  building  is  being  erected 
as  quickly  as  possible. 

The  New  York  State  Commission  in  Lunacy  will  erect  a  State 
Reception  Hospital  and  Dispensary  for  the  Insane.  The  Board  of 
Estimates  and  the  Aldermen  of  New  York  City  have  authorized  the 
purchase  of  a  piece  of  property  200  x  250  feet  between  Seventy-third 
and  Seventy-Fourth  Streets,  overlooking  the  East  River,  for  the  pur- 
pose. The  land  will  cost  $146,000,  and  it  will  be  leased  to  the  state. 
The  Lunacy  Commission  will  expend  $300,000  in  buildings. 


MINOR  INTELLIGENCE.  287 

After  a  more  or  lesc  successful  career  of  twenty-three  years,  the 
Ontario  Medical  College  for  Women  has  been  discontinued,  owing  to 
the  establishment  of  coeducation  in  the  Medical  Department  of  Toronto 
University.  The  attendance  has  been  growing  smaller  each  year,  and 
a  disruption  was  the  inevitable  outcome. 

One  hundred  two  candidates  received  the  degree  of  Doctor  of 
Medicine  in  Philadelphia  on  June  13,  the  event  being  the  CMie  hundred 
fiftieth  commencement  of  the  University  of  Pennsylvania.  The  address 
of  the  occasion  was  delivered  by  Professor  John  Bach  McMaster,  of 
the  history  department  of  the  University. 

The  thirtieth  annual  meeting  of  the  American  Dermatological  Asso- 
ciation was  held  in  Qeveland,  Ohio,  May  31  and  June  i  and  2,  1906. 
The  following  officers  were  elected  for  the  ensuing  year:  President, 
Doctor  Arthur  Van  Harlingen,  of  Philadelphia;  vicepresident,  Doctor 
William  A.  Pusey,  of  Chicago;  secretary-treasurer,  I)octor  Grover  W. 
Wende,  of  Buffalo.  A  number  of  excellent  papers  were  read  and  dis- 
cussed, among  them  being  one  by  Doctor  William  F.  Breakey,  of  the 
University  of  Michigan. 

The  Chicago  Medical  Society  has  been  considering  the  "contract 
practice"  question.  A  protest  was  raised  by  the  Douglas  Branch  of  this 
organization,  and  the  referendum  showed  that  358  members  were 
opposed  to  perpetuating  the  practice,  while  201  were  of  the  opinion  that 
the  present  system  should  continue  in  vogue.  The  total  membership  is 
1,928,  and  inasmuch  as  the  by-laws  require  that  fifty  per  cent  of  the 
members  must  engage  in  a  referendum  in  order  to  insure  its  validity 
the  vote  was  far  from  being  decisive. 

That  the  conduct  of  confinement  in  case  of  triplets  is  not  always 
pecuniarily  remunerative  was  demonstrated  recently  in  New  York 
City.  Some  time  ago  a  grocer  in  the  Borough  of  Queens  engaged  the 
services  of  a  physician  to  deliver  his  wife.  The  stipulated  fee  was 
eighteen  dollars,  but  after  discovering  that  the  procedure  contem- 
plated dealing  with  triplets,  the  physician  increased  the  charge  to  $50, 
which  the  grocer  refused  to  pay.  Litigation  ensued  in  the  Jamaica 
Municipal  Court,  and  the  jury  decided  against  the  plaintiff,  notwith- 
standing the  fact  that  the  case  required  the  services  of  two  extra 
medical  assistants. 

Because  of  the  utter  disr^^rd  which  quacks  and  venders  of  nos- 
trums evidenced  for  the  law  pertaining  to  the  practice  of  medicine, 
Judge  Green,  of  New  York  City,  has  evolved  the  following  clear  and 
simple  definition :  "The  practice  of  medicine  is  the  exercise  or  per- 
formance of  any  act,  by  or  through  the  use  of  any  thing  or  matter,  or 
by  things  done,  given,  or  applied,  whether  with  or  without  the  use  of 
drugs  or  medicine,  and  whether  with  or  without  fee  therefor,  by  a 
person  holding  himself  or  herself  out  as  able  to  cure  disease,  with  a 
view  to  relieve,  heal,  or  cure,  and  having  for  its  object  the  prevention, 
healing,  remedying,  cure,  or  alleviation  of  disease." 


288  RECENT  LITERATURE. 

Th